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					                  A Conversation with
                       Eric Dyken
Bingham: We are in Seattle with Sleep 2009, a joint meeting
of the American Academy of Sleep Medicine and the Sleep
Research Society and we’re with Eric Dyken, Director of the
Sleep Disorder Center at the University of Iowa Hospitals
and Clinics and is an expert on obstructive sleep apnea and
narcolepsy, epilepsy. Eric, last time we met, two years
ago, at that point, we were bemoaning the fact that
according to the National Sleep Foundation, there are forty
million Americans with some form of sleep disorder. I hope
things are getting better, at least awareness has been
raised or something. Is there, sort of, a stake the Science
Report can give us? Have we moved forward?

Dyken: I think that awareness has been increased,
especially for the public and I believe, for example, the
International Stroke Conference, there was a specific
lecture that Dr. Antonio Culebras brought in regard to the
association between untreated sleep apnea, stroke, a
variety of problems including cardiac dysrhythmia, and
possible, even, death. So I think scientific meetings are
starting to recognize sleep as a specific subset of
medicine and especially the lay population, at least from
the numbers I am seeing in my clinic.

Bingham: So, most people obviously don’t get enough sleep.
Is that a fair statement?

Dyken: I wonder if it’s most people, and it’s relative,
isn’t it. I’m sure infants do. ultradian rhythm. But as we
age, sleep demands are a little bit different. When you go
to sleep early in the day, early at night, late in the
morning, circadian rhythm problems with shift work. I would
say we probably, in this society, western industrialized
society that works on the twenty four hour clock, we
probably don’t get enough sleep because if we work harder,
burn the candle at both ends, we are more successful in a
westernized, industrialized society. So I believe in
America, in the United States, we probably, on average,
don’t get enough sleep. That seven to nine hours that
Grandma said you always needed.

Bingham: How do you change the situation? So that you are
getting more sleep? If you are talking about burning the
candle at both ends, at one end, lets say, is the time it
takes you to get to work, unlikely to be able to change
that because you’ve got to drive, that we are
industrialized, and so on. So do you have to go to bed
earlier, and that means you get less relaxing time? It’s a
complicated equation.

Dyken: It is complicated and I think the answer, at least
an approach to treating the problem of not getting enough
sleep depends on the individual, whether they’re a shift
worker, whether they’re in the military, whether they’re on
an on-call basis on a regular response time, so I think
that’s dependent on the individual. A marathoner that’s
trying to make it from one end of the United States to the
other on a record time. When is the efficient time to
sleep? So I believe that that’s probably a very variable
answer. For children who have to get to sleep early but
they’re phase delayed and they’re used to staying up later
and have a need to sleep in later I know we are trying to
address that on many levels. So I think, again, that the
answer is being addressed, for example, Mark Maholwald and
Mary Carskadon have encouraged certain areas where the
children actually get to go to sleep later because young
children, adolescents, often are phase delayed. And in some
areas, I believe in Kentucky, Lexington, they actually
found that there were less deaths from teenage motor
vehicle accidents in the areas where these children were
allowed to come to school later, rather than the early time
where they may not naturally be more accommodating, feeling
more rested or less sleepy, so safer drivers. So I think a
lot of these issues are slowly being addressed and that’s
one example.

Bingham: You’re a father, you’ve got a family, you work in
medicine, you’ve been through medical school where all the
doctors look tired and sleep deprived.let’s put you in
control now, you can change the system. What would you do
to make people get enough sleep and yet be able to go to
school enough and be able to go and socialize enough and go
to work on time. To accommodate ideal solutions for sleep
medicine, obviously means it gets intimately involved with
the entire structure of the family and the education
system.

Dyken: If they actually implemented what is hypothesized,
would be the best waking time, sleeping time for the
children, it would destroy me. I drive my kids to school. I
have to drive early because that’s when I need to be at
work. And I think that’s exactly what you’re alluding to. A
societal change for me would be devastating. How could I
possibly drive my kids to school and that would be
devastating psychologically, maybe physiologically, but
they are all finding that they need to follow my schedule,
for the most part and if they change that schedule, I would
have to adjust and I don’t know if I could accommodate that
well. So one simple change in waking time and sleeping time
for just the group of children, just the adolescents could
make major societal changes cost an awful lot of money and
an awful lot of controversy in making those changes. And
that’s just one issue. Getting my kids to school on time,
at the right time and again, shift workers, you had
mentioned that our people addressing these issues.

I was asked to give a lecture at the casino. Twenty four-
seven. And the owner of the casino, he had noted that there
were some lawsuits because people were falling asleep on
the shift work trying to go home. They were steadily sleepy
and he wanted to address this issue and he formally had us
come in, give a lecture on sleep hygiene to all of his
shift workers. We gave them some tricks, how they could get
better sleep and how they could stay up easier on those
night shifts and when they went home they did a variety of
things like the blackout lights. Judicious use of
melatonin, making sure that they kept their schedule of
sleeping during the day seven nights a week and sometimes
they even selected for the appropriate person for shift
work. Generally younger people, night owls and there are
specific questionnaires that you can take that show your
tendency to be a better night owl or shift worker. So as
you asked earlier, are things being addressed? I think they
are being addressed slowly, in a piecemeal fashion and
based on a little bit of science, but then addressing an
awful lot of major societal issues that changes would be
expensive to make and are the risks of not sleeping enough
really worth the benefits to society as a whole.

I don’t know about you, but some of the best work I ever
did, when I got my tenure, I hardly ever slept. I think I
could do two or three days in a row with no sleep. Dead
tired, then, when I reached my forties, I remember falling
asleep going to pick my children up from school and pulling
off to the side of the road, calling my wife on the cell
phone and saying you go get the kids, this is dangerous,
and doing a very bright thing, driving myself home another
thirty miles. Still, those societal issues, and knowing
that sometimes burning the midnight oil makes us
successful. And we see it in medical school, and for our
medical residents, they’re limited because of the Libby
Zion Case, limiting their hours to eighty-hour work weeks
and made further and further cuts. If they had made that
cut to me I wouldn’t be as successful as I am. If they made
demands where I had to sleep, and I believe in sleep, what
a tough world it is. So, I think, to become a great
athlete, to become a great academician, it takes a little
bit of pain, but how much pain can we take? How much sleep
deprivation can we take? Because the last thing a truck
driver remembers before falling asleep behind the wheel of
a forty ton rig is being wide awake. So when does that
happen, just like that. And you only get one chance to fall
asleep behind the wheel of a forty ton rig, they tell me,
for the most part.

Bingham: How serious is the sleepless driver issue?

Dyken: I believe it’s very serious. I remember Dr. Dement,
when he started looking at apnea in truck drivers.

Bingham: This is William Dement at Stanford?

Dyken: Dr. William Dement helped me get my tenure, good
friend, I would say. And, in fact, Dr. Dinges from
Pennsylvania had said we have the best, safest truck
drivers in the world. Remember that, they are the best,
safest truck drivers in the world, probably because of a
lot of this early work. When they fall asleep at work, I
think he said 4.2, 4.6 people go with them to the grave
because you don’t slow down in the early stages of sleep,
you just keep right on going through what ever is in front
of you. And because of a lot of that early research, Dr.
Dement had done and through Stanford colleagues, a lot of
people are a lot safer on the road because the truck
drivers are following very strict rules and again if you
talk to a lot of them, maybe too strict. That Machiavellian
limitations on what they can do doesn’t fit everybody’s
schedule, but probably the safest truck drivers on the
road, but still, on a weekly basis, even in Iowa, there’s
someone who falls asleep, not just truck drivers, just
every day people.

That little girl many years ago who fell asleep driving
home, working in the summer, trying to save money for
college, she took a wrong turn off a back country road,
upside down, under water in a drainage ditch for a few
days, lost both legs. Now she is a spokeswoman for
orthopedics because she was given new legs. I think she
should have been a spokesperson for the sleep societies
because she was pathologically sleepy and that could have
ended her life. It’s not just truck drivers. It’s our
children, it’s our truck drivers, it’s me, and my thought
is, it’s probably underreported. Because when there is a
death on the road, there are a lot of signs that can
suggest someone fell asleep, but when they are looking at
that individual on a pathology slab, it’s awful difficult
to tell was this person in this situation because the fell
asleep behind the wheel. I think it’s underreported, I
think it’s a major problem.

Bingham: This is a bazaar question, I know, but are there
any industries where people are actually monitored while
they’re at work so that there are video records of them
actually falling asleep on the job?

Dyken: I wonder about that. There was in my profession and
it led to the dismissal of an individual, but it was, sort
of, serendipitous because it was part of the job, there was
video monitoring going on, and just happened to catch
someone falling asleep.

Bingham: Just what you said, someone falling asleep just
like that, so and I thought you mentioned that you had some
videos of it.

Dyken: Well, we do have some video and I got to get you
that permission, but they’re doing a lot of work right now
with a driving simulator and two of my colleagues, Matt
Rizzo and John Tippin have been working with people with
obstructive sleep apnea and residual sleepiness that is
associated with that prior to being treated with,
generally, continuous positive airway pressure therapy. So
you’ve taken a group of people, highly suspected of having
sleep apnea, and we’ve monitored them for sleepiness using
a driving simulator to see how their performance changes
pre and post therapy, and a lot of that data is presently
pending for publication but there is some indication and as
I’ll show you on that film, the individual falls asleep,
then a nice place to wreck on a driving simulator, but goes
off the road and has a wreck. Sort of a proof in the
pudding kind of thing.
Bingham: I read a paper, recently, by Immanuel Mignot about
narcolepsy, which is a rather unusual thing. I’ve actually
seen dogs with narcolepsy just running along in a field and
then poof, they’re straight over on their sides. It turns
out that narcolepsy affects one in every two thousand
people, which is quite a significant number. And the
suggestion is that it might be an autoimmune disease. Does
that have any resonance with you?

Dyken: I think that’s the present thought in regard to
etiology. It makes sense, the term heuristically pleasing.
It just fits a whole package. You live in maybe the more
northern hemisphere, you might be more exposed, or be of a
genetic lineage that is more susceptible to a certain viral
entity, let’s say, and you get that bad cold, that bad flu
and at that time, your autoimmune system reacts in a rather
aberrant fashion, hits these latter nuclear cells and the
hypothalamus and recognizes them as being abnormal, and
with repeated flues or colds or immune susceptibility
periods, you gradually destroy those cells, which we
believe is the cause of narcolepsy with cataplexy. And
those cells have a very specific neurotransmitter chemical
protein called orexin, hypocretin, named two different
names because it was simultaneously discovered by two
different groups, but that paucity of an awaking
neurotransmitter is the cause, we believe, of narcolepsy
with cataplexy. But it fits in a very pleasing way with an
autoimmune phenomena and that it generally occurs in
adolescent period, and we’ve got a few cases, just my
anecdotes, of young kids, bad flu, afterwards falling
asleep in class, funny jokes, cataplexy, fall to the
ground, and in fact, I’ve saved some CSF, cerebral spinal
fluid, that I’m holding, Dr. Kushida says he’ll let me know
when they start to run the CSF levels of orexin,
hypocretin, but I’ll bet you money that she’s developed
narcolepsy right after this flu like period. But again, I
bet there will be more case reports, anecdotal and
retrospectively looking for these cases because of some of
that work that hopefully, in the future, the research will
show cause and effect with some specific entity, possibly
viral, that you’re predisposed to infection in that
specific area of sleep/wake mechanism.

Bingham: Suppose I put you in charge of the system. Put you
in the cabinet, maybe, so that your task was to get people
enough sleep, but allow them to still go to work and still
go to school. What would you do?
Dyken: That’s why I vote. I don’t want that job. I think it
would be horrific. It is tough times, we are all in the
red, but what I would propose, as we’ve suggested, I would
go to the experts. I know that Mark Mahowald, Mary
Carskadon, in regard to the adolescents may be going to
school and hour or so later then they are presently going
and then trial areas, where we can do studies to
scientifically show that there’s some evidence that the
children perform better, that they are safer on the road
when they are coming to and from school. I think in regard
to the military, there’s some indication with Dr. Dinges,
etcetera. A lot of the people from Pennsylvania, I’d go to
the expert and look at some small level plans, pilot
studies and see if implementing certain changes in, for
example, the military, leads to safer, healthier, more
productive soldiers. I think the same thing with shift
work. I think a lot of that, Dr. Czeisler, etcetera, from
Harvard, if they could take a video camera into the people
of the shift work in the powerplant, and implement certain
therapeutic recommendations, whether it’s melatonin use,
bright light therapy, but I think that would be the way to
start. Look at the experts. Look at small pilot studies in
a variety of different ways and I think data driven
scientific evidence is going to be expensive to come up
with, but is what’s going to change public policy, not just
my long white coat, saying that I run a sleep laboratory
and I think everybody should, because I have a bias. I
think everybody should sleep very well and I think that
it’s good for business for me, so I obviously have a bias
and I think that’s why science needs to be done. It’s
expensive to do. The small studies need to start before the
big expensive ones but public policy will change with data
driven science.

Bingham: Doctors, as portrayed on television, are not the
best. They all look haggard and drawn and in deep need of
sleep.

Dyken: You know, I honesty believe, if I hadn’t sleep
deprived, I wouldn’t be a doctor because I’m not that smart
and I had to work hard. When I was an undergrad, I drank so
much coffee. I remember I was beating a hundred beats per
minute. It’s down to forty now. I almost died, I told you,
driving my car. But my thought is, I’m happy to be a
doctor. I’m lucky to be alive and I’m glad no one said you
must sleep this many hours. Actually, we can’t even do that
with the medical students. We tell them they can only work
this many hours, but what does a type A personality do?
They go back home and do five million other things. They
play guitar, they sing in the choir, they have research
projects, and they do clinical work. They look at their
family members and play with them on the weekends. They
still burn the candle at both ends. Does it necessarily
mean and how do you mandate this? And you even suggest
this: ok kids, this Christmas Eve, let’s get to bed early.
I’ll give you this candy bar, you’ll get extra presents,
there will be some money it, just get to bed. They’re going
to be so excited. You ever try to get a kid to go to sleep
early on Christmas Eve? It cannot be done. My thought is,
how do you mandate enough sleep? And as you know, there’s a
broad spectrum of sleep necessity and most of us think
about seven to nine hours for most adults but there are
some short sleepers and some long sleepers. And
physiologically, what is best for any given individual?
That comes tough.

Bingham: You would imagine, if you were a Martian, just
arriving, isn’t that something that people just do
normally? Just sleep. That’s what they do at the end of the
day, they sleep. But it is more complicated than that isn’t
it?

Dyken: There’s another question, like the martians, if you
watch family members burn to death in a trailer fire, do
you think you are going to get a good sleep that night?
What do you think the response would be on a questionnaire?
I think 99.9 would say you have insomnia. You will not
sleep well. We know it. Why is that? What we could do,
after a horrific event like that, is we could deep sleep
for days, maybe months. Oh my goodness, trauma, everybody’s
going to be asleep. Biggest problem in the military is all
the sleeping soldiers. They saw a great big explosion, now
they are all falling asleep, but we know it’s not that way
because of catecholamine, central nervous system cracks,
the hypothalamus, autonomic systems that have biochemical
concomitants that make us stay awake. But, just as
fascinating are the people with Seasonal Affective Disorder
who can have that same kind of depression and maybe even to
a suicidal extent, decrease light exposure and they sleep
all the time instead of having the insomnia we just had
with a different kind of an affective problem, if you will.
So it is interesting, the martians can come down and say
well, yes, they sleep because it’s restorative isn’t it?
And do we have to sleep? I was reading about that, some of
our colleagues, in the great Kryger, Dement and Roth
principle and practice that all of medicine, that all our
students have to read before they take the sleep. We know
that if you sleep deprive an animal, the great studies of
[unintelligible] in Chicago many years ago, and I know
that’s a bit of a controversy, because animals died. You
sleep deprive them for fifteen, sixteen, twenty some days,
they die. The core body temperature goes way, way down,
basal metabolic rate goes way, way up, they get neurogenic
lesions across the back and they look horrific. They just
burn themselves up and they die. We’re really not sure why
they die, but there is something necessary about sleep.
And, maybe more specifically, REM sleep, that keeps them
alive. Restorative, if you will.

And I know at the last meeting, they showed that kid out in
California, it was a Stanford project, what did he get?
Eleven, twelve, thirteen days, and at day eleven he was
shooting baskets. He was still alive. And I don’t know,
unless there’s a pathology, like fatal familial insomnia,
if we really have someone who has been pushed beyond the
limits, who has died of sleep deprivation, and I know it’s
a big controversy now with the Guantanamo Bay, now they
have let it known that sleep deprivation, for two or three
days, I’ve done that, but I did it because I wanted to. No
one was scraping their fingernails on a chalkboard or
threatening to water board me, or telling my family may
suffer detriment but the question is, do people, and I
think some of the experts said maybe a person, a human
being’s metabolism and body mechanisms are such that maybe
they wouldn’t need sleep at all. Maybe they could actually
sleep deprive for long periods of time, I don’t know that.
That would be an unethical study to actually do. I mean
that’s where the clinical research is very limited. But
does a rat necessarily correlate, parallel, the fineness
you see with the human. Although we do know that people who
sleep much, much less than that seven to nine, or much,
much more, tend to have, in general, higher morbidity and
mortality rates and probably are not going to live as long
as you and I are because we are sleeping seven to nine
hours a night every night.
Bingham: Now the interesting thing, just to follow up on
your thing about how productive you can be with screen
culture, and I understand that. It makes a lot of sense,
it’s just that you also said that you didn’t need to go to
a meetings anymore, and that’s one of the things that comes
out of this, which is people don’t necessarily have as much
social interaction.

Dyken: Yeah, that’s why I’m here today. I think it is an
important element, and it is very interesting with all the
cut backs, the concern is that you are just going to
socialize, but a wise old sage told me that it’s important
to meet your colleagues, it is important to see people face
to face. It is important to bring your data and in general
when we are presenting, when we are inviting speakers, when
we do have research to present, that’s very, very important
to have the face to face. I think that there is something
about the face to face that the screen can’t replace, but
I’m not sure how well to define it. But the economics are
taking care of that for me, because in many of our
departments, you are given one lecture or none because we
just can’t afford it. I think, again, we can’t
oversimplify. I think it’s helped me to become more
economic and more efficient with my meeting attendants so
that I save money for the department. I don’t know if
that’s necessarily a good thing either.

Bingham: If sleep is so intimately connected with all the
remaining functions of the body, now with gene expression,
with your daily performance, and so on. You’d think, I’m
playing Devil’s advocate here, but you’d think that it
would be the most important thing to figure out and that by
now we would have it nailed. Why are we still saying we
don’t actually know what sleep is for, evolutionary? We
don’t know if somebody sleep deprived actually would die
whether they catch up with little naps. Why do we still not
have this field nailed?

Dyken: Well, I think it’s because animals other than humans
don’t really one hundred percent translate to human beings
and Mangella is dead and I don’t think we used a lot of his
data. There are certain things that you just can’t
scientifically prove in a human, although you could, but
you may not, because of the ethics of the element. And I
was reading something where they talked and scientific
proof in a human, compared to a quote on quote lower level
mammal study is all relative, you have to look at even that
with a grain of salt and I’ve had doctors call me and say
Dr. Dyken, I have a patient who never sleeps. And I say
bring them to my lab, I’ll monitor them in all the time
they don’t sleep. That patient never comes to my office. I
hear all sorts of things but I’ve never seen the animal.
What would happen if you actually, and how would you devise
a safe experiment to keep that person awake to see if they
could really. That’s just an interesting fundamental
question. Have you ever seen a person who never sleeped and
lived? Or could you make a person not sleep? And I don’t
think it’s ever been done.

Bingham: Assuming the reality TV shows right now where
people are willing to have cameras there all day long, you
would think that they would be willing to be guinea pigs
for sleep research.

Dyken: But they would still fall asleep unless there was
something to induce and I think the beauty of 2820 was that
he was able to overcome with his animal studies the
avoidance of a large hammer that came down on that rat and
killed it. He had a very ethical way, he had a tub and
everytime the rat would fall asleep it would push him into
a little bit of water and rats don’t like to be in water
that’s not their own so they would pull out and that would
keep them awake without causing direct harm to the animal.
But to a human being we know that right now, that
Guantanamo Bay that just raised a lot of ire, how could you
possibly keep someone up three days in a row? And my
thought is, well, we all know, I mean it’s just what we
know. But that’s far from science, isn’t it? Well you know
it is, and that’s not going to change public policy and all
the dollars that are implied by changing the public policy
that we’ve talked about. Still a fascinating question,
could you keep a human up forever?

Bingham: Tell me a little bit, just give me a paragraph
about the importance of, or the destructive nature of, or
cures, solutions, possibilities, and how widespread is
obstructive sleep apnea?

Dyken: Some people have estimated, and those numbers may be
going up, the last I recall, about seventeen million plus
people in the united states running around with obstructive
sleep apnea, depending on your definition of what apnea
actually is. And it’s a variable definition, especially in
relationship to risks for a variety of health related
problems. So, you know, obstructive sleep apnea is a major,
big, problem. The neat thing is you can treat it, for the
most part. Little kids, the tonsils, take them out. Large
problems in adults were often dealt with Continuous
Positive Airway Pressure masks and with good technicians
and technical support and a comfortable mask, can keep
someone falling asleep and keep them awake at work and
change their lives, I believe. But a lot of the long term
follow up on that, some people believe that you’ll lose
weight if you are a great big heavy person because your
leptons will be more functioning and a lot of metabolic
elements will improve but long term studies on that,
there’s a paucity of those. But we’ve seen a lot of great
anecdote in that regard.

There are many concomitants with untreated apnea. We know
from Terry Young’s group that if you do not treat apnea,
with an apnea hypopnea index of twenty events, where they
stop breathing twenty or more times per hour, those
patients have a statistically defined risk of developing
hypertension. Same thing with stroke. That same group
looked at four year aliquots over a twelve total year
period and people with a hypopnea index of twenty or more
per hour had a higher risk of developing stroke. Now those
are cohort studies, they show a risk, but not cause and
effect. And I think, clinically, it’s difficult to prove
simple cause and effect in a human being. Maybe in a rat
model and a lot of the work in the flies, etcetera, were
learning a lot on circadian rhythmicity but how a does a
fly, or even a Boston bulldog translate to apnea in a human
being. I am really interested in the far end of the
spectrum. I like to look at sleep apnea in critically ill
patients and in the critically ill patients, it only takes
a little bit of a lot of different things that could kill
that patient and we simply observe in these two patients,
one, we have a young man who’s come in, thin fellow, not a
great big pickwickian stereotype of sleep apnea and he has
viral encephalitis and he’s in a stuporous comatose state
and they call us to the ICU for an EEG because one of my
colleagues many years ago had shown that a temporal lobe
epileptiform discharge secondary to viral infection to the
brain can lead to cardiac dysrhythmia. They said, we think
he is having a very strange, unique seizural phenomena
where he’s seizing and the way we have the seizure evidence
is cardiac asystole, no heartbeat. So, fascinating,
morbidly fascinating, maybe we can come in there and adjust
with an anticonvulsant.

So my epileptologist, who, very close to polysomnography,
we use the EEGs on the head, he’s watching and since we
train our colleagues in sleep apnea and everything else we
do in the department, he’s watching this guy during the EEG
monitoring. He says, ‘I see the asystole, I don’t see any
epileptiform activity, the brain wave looks pretty good for
a guy who is stuporous and that’s a good finding, but he’s
doing this.’ And what he’s having is obstructive apnea and
he has paradoxical respirations that we teach our students
to look for and all of a sudden he goes back to sleep. And
again, when you are just visualizing, you can’t tell
whether he’s sleep, stupor or what, but on the EEG you can.
He says, he’s having obstructive sleep apnea, he’s sucking
in against the closed glottis, call that a Muller's
maneuver and that’s a sympathetic response, that’s not
necessarily healthy for this young man. So we brought our
poly symnography equipment up. We do portable studies,
because that’s the best way, in my opinion to study a
critically ill person. Have the nursing group, fellows, the
staff that is comfortable, knows them well, don’t drag them
off to my lab, bring the lab to him. And we saw these
prolonged apneas and that’s what we published and that’s
what you see in the film. The little bell goes over, ding,
ding, ding, the nurse goes over, see her pull up the
atropine, she’s calling the code, her injecting the
atropine. That’s just the strangest thing, he’s not even
losing his blood pressure when his heart stops. Usually
when the heart stops, there’s no blood flow to the brain.

Nurse: It actually increases, which is really weird.

Dyken: In this case, as [unintelligible] showed many years
ago, often times, there’s a sympathetic response and we
believe the vessels are clamping down to save the ischemic
penumbra, that there’s a protective mechanism in the apneic
state, which sometimes can go awry. That’s the fellow with
the encephalitis and we show, as the encephalitis is
resolved, the apnea resolved. What we show in the other
case is what Sullivan and Grimstein in the first principle
and practice bible of sleep medicine had talked about the
potential for rebound sleep in under treated CPAP and we
had a fellow who had a history of apnea and wasn’t using
his CPAP and he had just come in for a coronary artery
bypass graft. And he said the nurses have noticed that when
he goes to sleep he stops breathing. He’s got sleep apnea,
could you get his CPAP all tuned up before he goes home
because this is an expensive procedure, want his heart to
keep beating for a while. So we brought him on over, oh, he
had bad apnea. So we did a split night study, we diagnose,
and then we started the CPAP and we started cranking. And
it’s an art on how you increase CPAP. There’s now practice
parameters from the American Academy of Sleep Medicine on
how you would generally increase it. We were increasing it
relatively fast. Despite increasing it, it’s the deepest
state of sleep in regard to apnea, in general, REM sleep,
and he starts having a prolonged apnea even though she’s
increasing this pressure going up his throat. And it goes
for two minutes.

Then you see at the end tail of what we show on the film,
the end of the REM then you see diffused slowing which is
hypoxemic coma and then it flattens. Essentially, into a
brain death like pattern but we know he’s not dead because
eyes move, he’s still warm and there’s still a heart rate.
So we know he’s probably not dead even though his EEG is
flattened out. So my technician, after two minutes says I’m
not getting anywhere, she rips out his CPAP, she says ‘sir?
Sir?’ She shakes him around a little bit and he’s not
waking up and he’s still not breathing. She says lets call
a code, hyperextends his neck, breathes a few breaths,
starts doing external rub, does the chest compressions and
this guy has just had his chest cracked and he doesn’t
flinch. He’s not doing anything. After what seemed like a
minute or so, he opens his eyes, looks to the left and
she’s to the right and he has no idea what’s going on. He
moans and just sort of stares at her and after fifteen
minutes, this encephalopathic period resolves and he does
quite well for the next few years.

But I mean, there’s a lot of limitations in clinical
research, but I think, again, and that’s why people are
here, what we can hopefully do is prove the obvious so that
more people can be saved in regard to apnea, safety on the
road with circadian rhythms and good schedules for going to
school and going to work. The appropriate utilization of
medications and bright light therapies for people on the
shift works. And maybe, as Mignot had said with the
narcolepsy, if we can get these youngsters, generally
adolescents, when they get that infection that is attacking
that lateral nucleus wake center in the brain and treat
them with an antiviral or antibacterial or an anti whatever
it is, immunomodulating therapy and prevent them from
having narcolepsy. Well that’s what I think the whole
meeting is about. And in fact, I think you have to be here
to do that, I think you have to schmooze, I think you have
to meet colleagues face to face.