Clinical Fascination
Boredom can prove very personal.

A few weeks ago I sat down in the hospital cafeteria.  At my table was a polite, bright pulmonologist. He  expressed sympathy for my work: “I find sleep apnea so boring.”

For a doctor like him there’s isn’t much to do with sleep apnea.  Somebody  comes in.  They snore.  They’re tired in the daytime.  Their spouse complains.  There’s too much noise to sleep.

So you send the patient to the Sleep Lab.  She is found to have many stopped breathing episodes.  You bring her back another night.  You wake her at 5:30 in the morning, tell her she “did great” with a CPAP  machine, which blows air down her airway, opening it  while she sleeps. You write out a CPAP prescription to the medical device vendor.

Your job is over.  Done.  Clinical boredom personified.

Except for the fact that most everything about this model of treating sleep apnea is wrong.

Including the boring part.

The Standard Medical Model

American medicine is a business, right?  And in business, the goal is to make money.

Procedures make money.

When academics recognized how common sleep apnea was in 1980s, few foresaw it would become a monumental gravy train.  Those who did did very well.

A very  few sleep labs mushroomed into thousands.  Big money flowed to people who made laboratory equipment – with flakes of gold falling on physicians who ordered and read the studies. Yet the real money came with CPAP devices – and their follow-up parts.

Manufacturers made billions.  They still do.

The model used was simple. First test – as many people as possible.  Then give the ones who need them CPAP devices – in as many variants as possible.

However, this model has not done what it should for the public health:

1. Loads of people have real trouble using the CPAP device.

2. The majority of people with sleep apnea have insomnia – plus many other sleep and medical problems.

3. Sleep apnea is just part of a much wider public health problem – metabolic syndrome.  With the increase in obesity around the world, metabolic syndrome is set up to  help to an earlier death  hundreds of millions.

For sleep apnea is a systemic disease.

System Failure

Snoring used to be funny.  It’s not anymore.  For snoring marks a physiologic problem – the desynchronization of breathing and circulation.

When you have sleep apnea, your heart and lungs don’t  work together as they should.

This produces more than loud noises and daytime sleepiness.  For life you need energy.  That comes from oxygen (the lungs) moving into the circulating blood (the heart and blood vessels.)  Foul up that process and the problems are numerous:

1. More heart attacks and strokes

2. More depression and anxiety

3. Far less productivity, alertness and pleasure

4. If things get bad enough, more Alzheimer’s disease

5. More car wrecks and work accidents

6. Greater levels of inflammation throughout the body

7. More diabetes

8. More weight gain.

And so on.  So sleep apnea is really a systemic illness, affecting the whole body.

It’s treatment is systemic, too.

Treating Sleep Apnea

My pulmonary colleague is right.  If all you think about in terms of  sleep disorders is sleep apnea, CPAP becomes your treatment gold standard.  The rest is “details.”

Of course, if all you have is a hammer the whole world looks like a nail.

For sleep affects all of your  life.  Without sleep, you don’t just function – you can die.

So getting sleep right is important.

To treat sleep apnea properly you need to look at the larger picture:

A. That many people have apnea – and diabetes – because they weigh too much.  If you can change habits and lifestyle, the whole problem may go away – including the CPAP machine.

B. The effects of sleep apnea on work, marriages, pleasure and happiness are major. To fix these problems requires more than a prescription for a CPAP machine.

C. Lots of people hate CPAP.  It feels really strange.  It’s uncomfortable. It gets tangled up. It’s a pain to clean.

You need to have folks see why they should use CPAP, and how it can be used.  That involves whole changes in behavior.

D. People with sleep apnea usually have all sorts of sleep difficulties. The majority of people with sleep apnea have insomnia – even after they get a CPAP machine.  Insomnia  can be solved by a host of other techniques, including: cognitive-behavioral treatment; getting people to go to bed and get up at the same times (circadian treatment); weight loss achieved by walking after meals; rest-relaxation techniques.

It’s not just about the machine.

Profits or Health?

American health care is very good at generating income for large groups of people.  It’s much less effective at providing health – physical, mental, social and spiritual well-being – to the public.

Sleep apnea is a systemic illness.  It affects many millions of people, their families and their jobs.  It has system wide effects.

It needs systemic treatment.

To fix it in the future, we might start with banning junk food advertisements aimed at children. Recent evidence shows that if kids are obese at age 5 they’ll stay that way. For obesity, the early years may  count most.

But for clinical practice, the real issue is to accept that sleep apnea must be comprehensively treated. Much can be done with very basic stuff: fixing people’s basic sleep habits, how they eat, move, and rest. So that people can really function and enjoy life.

That involves talking to people.  Encouraging them.  Engaging their families.

It’s a lot of work.

And it doesn’t get paid anything like ordering sleep studies or CPAP machines. Often it doesn’t get paid at all.

It’s just necessary to fix the many different sides of sleep apnea.

Fortunately, it’s not boring.

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