Sweet dreams

Thousands of Manitobans have trouble sleeping at night and staying awake during the day. Some snooze at work, others get into vehicle collisions because they nod off while driving. Here's how one Winnipeg clinic is turning their personal nightmares into sweet dreams.

Thousands of Manitobans have trouble sleeping at night and staying awake during the day. Some snooze at work, others get into vehicle collisions because they nod off while driving. Here's how one Winnipeg clinic is turning their personal nightmares into sweet dreams.
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Sleep apnea

A field guide to sleep disorders

Sleep right, sleep tight

Winnipeg Health Region
Wave, Summer 2009

The irony of the moment did not escape Krystyna MacDuff.

For eight years, the Winnipeg woman struggled to stay awake. Now, she was lying on a bed at the Sleep Disorder Clinic at Misericordia Health Centre. Technicians in a room down the hall were waiting for her to nod off so they could begin to figure out the source of her nocturnal problems. And she couldn't close her eyes.

There were, of course, many possible reasons for this failure to snooze on demand. It might have been the strange setting. Or it could have been all the wires and sensors.

First there were the electrodes. They were attached to the top and back of her head to measure her brain waves. They were attached beside her eyes to measure eye movements. They were attached to her jaw, and there were even electrodes on her legs to monitor leg kicks.

Then there was the cannula, a modified oxygen hose, which was inserted under her nose to measure carbon dioxide levels and airflow when she exhaled. An electrocardiogram measured her heart rate. A pulseoximeter had been placed on an index finger to gauge oxygen levels in her blood. MacDuff was literally wired before bedtime.

But, as she recalls, it was embarrassment that was really keeping her from falling asleep. "In a way, I didn't want to fall asleep because I knew that I would probably snore," says the 61-year-old healthcare aide.

It wasn't the first time MacDuff was left feeling embarrassed by her sleeping habits.

For the previous eight years, MacDuff had waged a constant battle against falling asleep during the daytime. She would doze off at her desk at work. She would pull over to the side of the road between appointments and snooze for 15 minutes. She even had two minor fender benders because she could not control slipping in and out of consciousness because she was so exhausted.

One incident was particularly embarrassing: she dozed off at her own dinner party and awoke to the laughter of the other partygoers. 'You snore funny,' they told me. I was so embarrassed, I never invited my guests back again."

Like many people who suffer from a sleep disorder, MacDuff did not link her snoring to her fatigue - she just assumed she was getting older and losing her energy. It wasn't until her partner became worried after witnessing her stop breathing for 30-second spans in her sleep that she decided to see her family doctor. He surmised MacDuff may be suffering from sleep apnea, a type of sleep disorder, and referred her to the Sleep Disorder Centre for a sleep study.

Located on the third floor of Misericordia Health Centre, the Sleep Disorder Centre is essentially a collection of 10 rooms connected by closed-circuit monitoring cameras. At the centre of it all is the control room, which houses a bank of monitors and computers that keep track of the sleeping patterns of patients in the surrounding rooms.

Each evening at about 9 p.m., as many as 10 sleepless Manitobans walk into the centre, hoping that the five technicians and their assorted gadgetry will be able to determine whether a particular sleep disorder is keeping them up at night and fatigued during the day. During their 12-hour shift, each polysomnographic technologist (PSG Tech) is responsible for monitoring two patients with up to 16 different sensors per patient. Their job is to ensure patient comfort and safety as well as producing clear recordings and assessing treatment options. Contrary to popular belief, a sleep study is not just "putting someone in bed and watching them sleep"; it is a highly technical, labour-intensive process. The facility opened last summer, replacing two smaller clinics at Health Sciences Centre and St. Boniface General Hospital, to keep pace with demand for services.

And business has been brisk. Dr. Sat Sharma, a respirologist at the sleep centre, says the number of patients with sleep disorders in Manitoba has jumped during the last 20 years. The centre expects to receive more than 3,000 referrals this year, a significant increase over what the old clinics could handle. "In March alone, we had 400 to 500 referrals," Sharma says. Still, keeping pace with the rising volume of patients does pose challenges.

Demand for services over the last two decades has been steadily increasing, partly because of an aging population and increasing rates of obesity, two risk factors for disruptive sleep. The most dramatic of these cases involve people who suffer severe affects, including prolonged periods of insomnia, extreme daytime fatigue and deteriorating overall health. But many people may suffer from a sleep disorder and not even know it. Like MacDuff, they can go for years feeling physically tired and mentally exhausted and not realize it all has to do with a lack of proper sleep.

"If anything, it is the partner who will pick up on the problem, or someone who observes them sleeping," Sharma says. "Some people do wake up with a choking sensation (a symptom of a sleep disorder), but that is a minority. Most people wake up tired, and they would not know they were waking up hundreds of times during the night."

To understand the relationship between sleep, overall health and how obesity and age play roles in disrupting sleep, the biology of sleep itself bears a closer look.

Essentially, sleep has five stages: Stage one is called the introduction to sleep, lasting only a few minutes. We often experience sleep starts during this stage, a jolt or falling sensation that wakes us up. At this point, the brain is disconnecting from the outside environment.

Stage two is often referred to as the beginning of real sleep. Typically, the body begins to enter deep sleep at this point. The heart rate should slow down. Body temperature should decrease.

Stages three and four are deep sleep phases, known as slow-wave or delta sleep. The waves refer to brain activity. At this point, brain activity is slowing down, and the body is preparing to enter the fifth stage, rapid eye movement (REM) sleep.

Each stage prior to REM lasts about five to 15 minutes with all four stages of the non-REM sleep taking about 90 to 120 minutes in total. Upon reaching stage four, the brain will then revert back to stage 3 and then stage 2 before entering REM sleep, which lasts for about 90 minutes.

Dr. Eleni Giannouli, Medical Director of the Sleep Disorder Centre, says completing the cycle about every 24 hours or so is essential to good health. Sleep regulates growth of bones, muscles and organs. It allows the body to repair itself and helps regulate body temperature. Sleep also is important to our immune system and helps cleanse the body of toxins that build up while we are awake. The REM stage is particularly important, says Giannouli, because it plays a large role in promoting neural plasticity, allowing the brain to restore pathways needed to promote learning and consolidate memories. People who cannot complete the sleep cycle rarely achieve the deeper stages of sleep, including REM sleep - otherwise known as the dream state.

How important is a full cycle of sleep? Giannouli says a 1993-study by the National Institutes of Health in the U.S. found that rats deprived of sleep for weeks developed sepsis and eventually died. No evidence exists that a person has died from sleep deprivation, but cumulative sleep deprivation not only exasperates already existing illnesses, it also causes neurological impairment leading to depression, reduced libido, irritability, memory loss and anxiety.

To feel normal, most adults need about six to nine hours of sleep per night, though exceptions do exist. "Some people are short sleepers," Giannouli says. "So for them, sleeping five hours is not a problem because they do not have signs and symptoms of sleep deprivation." Other people may need more than nine hours. But once we start missing those needed hours of sleep, either by purposely staying up or because of a sleep disorder, a deficit builds up.

There are six major sleep disorders, including insomnia, sleep-related movement disorders (restless leg disorder, periodic leg movement disorder), hyper-somnolence (narcolepsy), parasomnia-related (sleep walking, night terrors and REM Behaviour Disorder) and circadian rhythm disorders, where the body's internal clock causes unusual sleeping hours.

In terms of sheer numbers, however, sleep-disordered breathing, or sleep apnea, is the most common sleep disorder. Apnea (the word means pause in airflow) can be broken down into two types - obstructive and central. The latter is often associated with Cheyne-Stokes breathing (CSB), and happens when the brain periodically fails to send a message to the muscles that control breathing. "This is periodic breathing, a waxing and waning pattern of breathing that is commonly seen in patients with heart failure," Giannouli says. CSB is seen in normal, developing newborns and in people suffering from heart failure or neurological diseases.

Obstructive apnea - where the airway is blocked and impedes airflow - is much more common than central apnea, Giannouli says. A person with obstructive sleep apnea will usually have breathing pauses of up to 30 seconds while sleeping. Although brief, these pauses result in lower
oxygen levels, and ultimately disrupt sleep. Once airflow has stopped, the sufferers choke and are briefly roused from sleep - even though they may not remember it. This process often repeats itself hundreds of times throughout the night, fracturing sleep patterns and interfering with the body's ability to reach deeper stages of sleep.

A major risk factor for obstructive sleep apnea is obesity. Experts say people who are overweight may have fat deposits around the upper airways that restrict breathing. A short, thick neck can also be a risk factor for the same reason. "When they (people who are overweight) fall asleep, their muscles relax and the effect of the weight doesn't allow enough muscle power to breathe properly," says Wayne Thompson, Chief Technologist at the Sleep Disorder Centre.

In addition to upper airway dysfunction, morbidly obese individuals may also experience hypo-ventilation (inadequate breathing) in their sleep. The inability to draw in enough air means carbon dioxide levels in the blood rise while the oxygen levels decrease.

In addition to leaving people fatigued and prone to nodding off at inopportune times, such as at work or when driving a car, sleep apnea and other forms of sleep-disordered breathing are significant because they will exacerbate other health conditions and may even be at the root of illnesses for some patients, says Giannouli.

The Wisconsin Sleep Cohort Study, one of the largest epidemiological studies on sleep ever conducted, found that people who suffered from even mild apnea or hypopnea were unable to think clearly, and experienced sleepiness, irritability and increased risk for high blood pressure. The study, published in 1993, also found people who suffered from even mild sleep disorders were at higher risk of being involved in vehicle collisions.

For those who scored higher on the index - which is a measure of the number of apneas and hypopneas during one hour of sleep - the health risks are much greater. Sleepdisordered breathing has been linked to higher incidence of disease and mortality rates among patients suffering from heart disease, diabetes and obesity. Evidence even suggests sleep-disordered breathing, obesity and the aforementioned diseases feed off each other. Obstructive sleep apnea has been associated with increased risk of high blood pressure, heart attack, cardiac arrhythmias, stroke and atherosclerosis. It also contributes to the development of insulin resistance, and possibly diabetes and lipid abnormalities (high cholesterol).

"It is a vicious-cycle relationship because the more obese you are, the more likely you are to develop a sleep disorder that may contribute to sleep deprivation," Giannouli says. And new studies have found that sleep deprivation may play a role in disrupting the metabolism and appetite regulation. "So, that may contribute to increased appetite, eating and obesity," she says. In addition, the patients wake up feeling tired and are less likely to engage in regular exercise. As a result, their health deteriorates, and they put on more weight, which causes even more pronounced sleep-disordered breathing.

While no recent figures exist on how many people in Manitoba suffer from sleep apnea or its lesser form hypopnea - laboured breathing during sleep - older epidemiological studies suggest it could be anywhere from two to 10 per cent of the population. One study published in 1982 by the Journal of the American Medical Association estimated that two per cent of women and four per cent of men suffer from sleep apnea. The Wisconsin study later found that as many as 10 per cent of the population in the U.S. could suffer from sleep-disordered breathing.

"My feeling is that the number is much higher," Sharma says, adding that he estimates there has been about a ten-fold increase in the number of diagnoses since the first sleep clinic opened in Manitoba in 1987. Part of the reason for the increase, he says, can be attributed to greater awareness and better diagnostic technology. But the population of the province has also changed. "Society has changed a whole lot in the last 25 years. Obesity rates have tripled or quadrupled since then," he says, noting that being overweight is a risk factor for sleep apnea. "The Wisconsin information is more relevant, but it, too, is old. We don't really know the scope of the problem." While new studies are underway, including one in which the centre is participating, Sharma is certain about one thing - thousands of Manitobans are in need of treatment for sleep disordered breathing, including many who may not even know it.

Although unable to sleep at first, Krystyna MacDuff finally did nod off that evening in the sleep centre. As she slept, her movements and vital signs - exhaling, inhaling, apneas, hypopneas, blood oxygen levels, eye movements - were recorded on a computer in the control room down the hall, while a technician watched on a monitor and assessed her sleeping patterns.

Within minutes of falling asleep, the monitor began to pick up irregularities in MacDuff's breathing. The technician was able to see her blood oxygen dip and her heart rate increase. Her body thrashed about as it struggled to take in enough air. The monitor displayed increased instances of hypopnea - laboured breathing - until the airway closed completely. At this point, her blood oxygen bottomed out until her brain sent out a signal that the body was starved of oxygen. She choked, woke up, experienced a spike in her heart rate, and continued the cycle over again several times an hour.

Normal sleepers will often wake up as many as 15 times an hour, says Thompson, adding most people often do not remember waking up. Sufferers of sleep-disordered breathing may wake up to 120 times in an hour, and they may never be consciously aware of the disruptions. "In this case, not only do they wake up, but the oxygen levels decrease, their heart rate increases because it's very traumatic to be choked in your sleep," Thompson says. "It's like driving a car down the highway, stomping on the gas one second and easing off completely the next." The process puts the heart under repeated stress, resulting in rest so fragmented that the patient hardly receives any of the benefits of sleep.

The study results showed MacDuff would stop breathing when the soft tissues around her upper airway narrowed and then closed, preventing her from breathing for about half-minute durations. She would have between 20 to 30 apneas in an hour while asleep, each time waking up, and then immediately falling back to sleep.

Interestingly, the reason for MacDuff's airway constriction was not self evident. She was not overweight and had a long neck with no apparent abnormalities. It was only after further investigation that Sharma discovered that MacDuff's problem arose from an incident about eight years ago. She had been cleaning coffee pots at work with bleach she brought from home. She took the bottle of bleach home, threw it in the back seat of her car next to some water bottles, and forgot about it. A few days later, she was thirsty while driving and in her haste, reached back, grabbed the wrong bottle and took "a slug of Javex." From that day forward until she received treatment, she says she likely suffered from sleep apnea.

Once MacDuff's sleep apnea was confirmed, the technician spent the second half of the evening treating her by using a Continuous Positive Air Pressure machine, known as CPAP. About the size of a shoebox, it blows a continuous flow of air through a hose into a mask that goes over the patient's nose. The positive airflow keeps the passageway open, effectively curing the obstructive apnea or hypopnea.

Often within minutes of being fitted with a CPAP, once the technician finds just the right amount of positive air pressure to keep the airway open, the patient stops snoring, the hypopneas and apneas disappear, and the patient falls into deep sleep, experiencing extended REM periods that may have been otherwise unattainable.

Following her visit to the centre, MacDuff took a CPAP machine home and has been using it ever since. The typical symptoms of her apnea - daytime sleepiness, irritability and fragmented sleep marked by choking - have disappeared. "Within two weeks of going on the system, I started to feel completely energized. I felt a difference in my overall well-being. It was like a wave of euphoria having all that air coming in," she says.

Now, she awakes from a restful sleep in the morning and hasn't taken a daytime nap since January. She looks back on her past eight years and wonders how she managed to function despite being so utterly exhausted. "I used to have to wake up with three alarm clocks. That doesn't happen anymore. I wake up and I'm ready to go before the alarm rings."

Joel Schlesinger is a Winnipeg writer.


About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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