Sleep Apnea – My Chat with Dr. Susheel Patil at John Hopkins University School of Medicine by Robin Gorman Newman

In an effort to continue to educate myself about sleep apnea, to further my desire to treat my case and to share with others who may benefit, I’ve been speaking with medical practitioners who are not treating me at present but are experts in the arena.

I had the pleasure to chat with Dr. Susheel Patil, and below is our Q&A.

When someone has been sleep deprived for a while, and if you endeavor to treat your sleep apnea, does it take time to feel good again?  Absolutely.  Given all the fragmented sleep someone has when they have sleep apnea, and even if someone doesn’t have it but doesn’t sleep well, you can develop a sleep debt that accumulates over time.  Once someone is doing successful treatment for their apnea, it can take almost a month or more of getting enough sleep and treating the underlying sleep disorder, before one really begins to feel rested.  Sometimes it can be even longer than a month.

Do you see any benefits of caffeine?  Not for the treatment of sleep apnea directly.  In terms of addressing some of the issues of the sleepiness that many people have with sleep apnea, it is something people do, and in that sense, it can be helpful in moderate doses but not after late afternoon.  Caffeine is a tricky thing because everyone metabolizes it differently.  One or two cups of coffee can stay in the bloodstream for 24 hours, and it can contribute to having unrefreshed sleep or difficulty sleeping.  So, you want to be judicious with it, and sometimes you have to experiment re: the right dosing.  If someone has a higher blood pressure, we advise against it.  It is a stimulant and can affect your heart rate and blood pressure.

How essential is it to stick to the same daily sleep schedule?  We are creatures of habit, and because we have an internal clock, it tells us when it’s time to go to bed and wake up.  The more we abuse it by going to bed one or two hours later or waking up at different times, it has a harder time adapting.  The more you can stick to a consistent schedule, the better your sleep is going to be over the longer term.

Do you consider sleep apnea epidemic, and if so, why?  It is a common disorder.  Much of it has to do with the obesity epidemic.  Men are more at risk than women.  Women will start to have increased risk after the menopausal transition.  And, age can be a risk factor.  Worldwide obesity rates are going up, and sleep apnea is traveling along with it.  The other reason is that people know more about what sleep apnea is.  We used to think of it as a disease of obese or morbidly obese people, we are recognizing that you can see sleep apnea in those you wouldn’t normally think about.

What is the most effective treatment, and what are some new treatments?  CPAP is considered universally effective, considering you can use it on a nightly basis. There much more uncertainty with other treatments.  Oral/dental devices are available as well, and while they are generally indicated for mild or moderate sleep apnea, there’s not always a guarantee that you’re going to complete resolve the sleep apnea.  You have to test the therapy with a sleep study to see if it’s resolved.

If someone is wearing a CPAP mask, do they still need to sleep on their side?  They can typically sleep in any position they want after they are appropriately set.  If someone has an auto CPAP device, then the pressure will be automatically adjusted as they move from their back to their side.

What is someone is prone to sinus conditions and allergies, is a nasal CPAP still viable?  That’s always one of the biggest challenges we have.  We do a lot of intensive work with out patients in terms of trying to address their nasal issues.  Longer term, they are usually more comfortable long term with a nasal CPAP because it is so much less bulkier versus a full face mask.

What if someone is a mouth breather? A nasal pillow will be less effective if they truly are a pure mouth breather.  In my practice, many say they are one, but they are actually a mouth breather because of the sleep apnea.  They breathe through their mouth if they are being asphixiated through their nose.  Once you open the airway by delivering air through the nose via the CPAP, many times, the mouth can close.

There are some who still have mouth breathing despite that, depending on the degree of the mouth breathing, a nasal CPAP is going to be difficult in terms of being successful therapy.

Do you see any benefit in doing tongue or throat exercises?  There is limited data available with respect to that.  In someone with mild sleep apnea, and if they really are adverse to traditional treatment, it may be a viable alternative.   The issue is doing the exercises correctly and if it can be translated into regular, everyday practice.  It’s a great area  that deserves more research, but it’s not something I recommend on a regular basis because of the lack of research.

Should someone with sleep apnea drive on a long trip?  If they are being successfully treated and getting adequate sleep, there is no reason they shouldn’t drive. They need to know their body.  If they aren’t treating it, it needs to be discussion between family members and their physician.  Particularly for severe sleep apnea, I will advise against them driving.  There are different laws in different states, and drivers with sleep apnea are considered at higher risk for automobile accidents.  We can’t predict which with the apnea will be the ones to have the accident.

How can you inspire and support someone to pursue treatment if they remain resistant to wearing a CPAP mask?  As hard as it is, it’s having a discussion about how the sleep apnea is potentially the spouse or family.  If they don’t take care of themselves, they are directly affecting their family’s happiness, and ability to function.  It helps for the patient to understand that.  A physician can be helpful in terms of talking about the risks such as heart disease, stroke.  If you have moderate or severe sleep apnea, and it’s untreated, your lifespan is potentially gonna be shorter than those who don’t have it.   Many times patients with sleep apnea don’t recognize that they are impaired, and we we tend to tackle things that directly impair us.  So, sometimes taking a different tact and talking about how it can impact long term health will have an effect.

If someone has sleep apnea, does that qualify them as having a disability?  I see insurance struggling with it.  Not all thing of it as a disability.  It is a health issue.  The issue relates to how it potentially impairs what you can and can’t do and your occupation.

Other than the CPAP and dental device, are there other treatments can be effective?  There are a number of different options including positional therapies in the right patients.  If a sleep study demonstrates that you have positional sleep apnea, those patients can benefit from sleeping on their side on a nightly basis.  Weight loss can improve sleep apnea, particularly if they have mild or moderate sleep apnea and can lose at last 20 pounds.  Beyond that, there aren’t a lot of approved therapies.  There is hypoglassal nerve stimulation — the new kid on the block.  For certain times of patients, it may be very effective.  There is strict criteria in terms of who is eligible for that kind of treatment.  If you are eligible, the studies have shown that it can work well.

If someone has a CPAP, and they feel like they need a break every now ‘n then or they have a vacation coming up, are they at risk during those down times if they elect not to use the CPAP?  It depends.  By and large my general recommendation is that they should take their treatment with them, particularly if they feel rested when they use the CPAP.  If you have more milder forms, it may be okay, but you should discuss with your physician.

If someone had a sleep test at home, do they need to have one in a lab as well?  Home sleep studies focus on diagnosing and evaluating for sleep apnea only.  They are not gonna give you any other information about other sleep disorders.  Despite the name, a home sleep study doesn’t evaluate sleep.  They assess breathing but not sleep itself.  If a home study shows you have obvious sleep apnea, they are generally pretty good, and there is really no reason to come into a lab.  An in-lab sleep study may give you a better sense of the cause of the sleep apnea because you are observed and seeing what is happening to brainwave activity in relation to your sleep.  Sometimes poor sleep can influence how bad the sleep apnea is and have nothing to do with having a narrow airway.

What advice would you offer someone struggling with wearing a CPAP mask?  CPAP is not the most natural therapy for anyone to use.  if it were, we probably would have been born with masks on our noses.  It’s important to recognize that some may do very well from the starting gate, but a lot of people, it takes time to get used to it.  And, it can take several months or even longer.  That said, if you’re struggling, don’t struggle with it alone. Talk to your physician or a sleep physician.  Use resources available to you.  If you have a good medical equipment provider, many times the CPAP specialists or respiratory therapists they have can provide useful tips about how to use their CPAP.

One thing physicians don’t do well as a group is to start to think about alternatives sooner if it’s clear someone is struggling with CPAP.  I’d rather have a patient who is partially treated than not treated at all. For example, even if you might think an oral device might not be effective, it could be.  Eventually they would need a sleep test to see.

It’s perseverance and making sure you have someone you can go to who has the resources and expertise in terms of dealing with individuals who are having difficulties using CPAP.  Not every physician group or center may be equipped to do that.

Anything you’d like to add?  The important thing is that if you’re tired or sleepy, recognize that you may not have to be tired or sleepy.  There may be a good explanation for why that may be address.  So, you want to talk about these issues with your doctor to see if you would benefit from further evaluation.  Just because you snore, doesn’t mean you have sleep apnea, but still have the discussion with your physician to see whether it’s something of concern.  Often people have had sleep apnea longer than they know.


Susheel P. Patil, MD, PhD is an Assistant Professor and Clinical Director of the Johns Hopkins Sleep Medicine Program. Dr. Patil received his undergraduate degree from Pennsylvania State University. Subsequently, he graduated with his medical degree from Jefferson Medical College prior to pursuing training in Internal Medicine at Case Western Reserve University (University Hospitals of Cleveland). Following a year as Chief Resident at Case Western, Dr. Patil came to Johns Hopkins for fellowship training in Pulmonary and Critical Care Medicine, during which he also completed training in Sleep Medicine. Dr. Patil also received a PhD in Clinical Investigation at the Johns Hopkins Bloomberg School of Public Health. He is board certified in Sleep Medicine, as well as Pulmonary and Critical Care Medicine.

Dr. Patil has been active in numerous committees and leadership roles in the Sleep and Respiratory Neurobiology Assembly of the American Thoracic Society and the American Academy of Sleep Medicine, and the American College of Chest Physicians. He has organized or spoke in numerous scientific symposia at the international meetings related to sleep medicine. He is the author of more than 30 publications, and has given invited lectures throughout the US. He is the Associate Director of the ACGME Sleep Fellowship at Johns Hopkins. Dr. Patil is also active in sleep medicine related public policy at the state level with roles in the Maryland Sleep Society and Chair of the Polysomnography Practice Committee of the Maryland Board of Physicians.


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