Topic:PH and Insomnia
Date:  January 22, 2001
Guests:  Dr. Kingman Strohl, University Hospitals of Cleveland, Department of Pulmonary and Critical Care Medicine

<Moderator> ***ATTENTION***
<Moderator> ***Welcome to the PHCentral Guest Expert Chat
<Moderator> ***Our Guest Expert today is Dr. Kingman Strohl, a sleep a study specialist from
   University Hospitals of Cleveland
<Moderator> ***Our topic is PH and Insomnia
<Moderator> ***The moderator today is Michael Szczepkowski - that's me!
<Moderator> ***Here are the guidelines for today's chat:
<Moderator> ***If you have a question, please send a "?"
<Moderator> ***I will keep track of who is next in order and then....
<Moderator> ***call on you to ask your question.
<Moderator> ***Dr. Strohl will answer your questionand then I will ask if you to ask a followup
   question if you have one.
<Moderator> ***When you see some text followed by "..." that means the person...
<Moderator> ***still has not finished typing.
<Moderator> ***It would also help if you had your question typed and ready to submit when I call on
   you.
<Moderator> ***There will be a log for today's chat posted on PHCentral.
<Moderator> ***OK, we are ready to begin!!
<Moderator> *** If you have a question...
<Moderator> ***please type and send a "?"
<Moderator> no questions??
<Diana> ?
<Kingman Strohl> Forgive me, but I was working on background. Good for the transcript. Insomnia.
   Definition: the report of inadequate or insufficient sleep. Two general types: failure to initiate sleep
   and failure to maintain sleep in amounts to feel as though you have had enough sleep. Chonology:
   Acute (<2 weeks), Sub-acute 2-16 weeks. Chronic: >6 months. Most often insomnia is associated
   with stress and with illness/medications/or lifestyle. There are other facts. On NBC news the science
   report led off with the discovery that there is a genetic basis for advanced phase syndrome, a
   condition where people go to bed early and get up early. The hope is to try to unlock the genes and
   proteins that govern to some extent our preferences for sleep during a 24-hour day. So the first thing
   to think about in regard to chronic insomnia is to think of your preferences for time of sleeping. The
   other major factor is how you get ready to sleep. Routine and the like for making a bed and the
   comfort of being in a s
<Moderator> Thanks Dr. S.!
<Moderator> Diana, go ahead with your question.
<Diana> Is it possible for a goiter to cause sleep apnea/obstruction?
<Monica> ?
<Kingman Strohl> Goiters and sleep apnea. I have seen goiter and sleep apnea. Before surgery there
   may be some upper airway obstruction. and more if there is also a low thyroid hormone. there are
   also reports of obstructive sleep apnea after surgery.
<Moderator> Diana, do you have a follow-up?
<Diana> No Thank you
<Kingman Strohl> Oh, goiter is an enlargement of the thyroid gland in the neck.
<Moderator> Monica, go ahead.
<Monica> I use Tylenol PM to help me sleep, sometimes I just take a half of a caplete. Sometimes a
   whole one, but sometimes it doesn't work, can you recommend anything?
<Kingman Strohl> Inventory your sleep habits. The sedating effects of Tylenol PM works if you are
   already sleepy.
<Monica> What do you suggest to fall asleep better?
<Moderator> Monica, do you have a follow-up?
<Monica> see above
<Kingman Strohl> Sleep habits include sleep routine, avoidance of caffeine 6-7 hours before sleep if
   you are over 40 and the like.
<Monica> ok, thanks.
<Kingman Strohl> Exercise helps too. The increase in temperature with exercie if it happens 1-2 hours
   before sleep can help initiate sleep.
<Moderator> Other questions? send a "?"
<annie> ?
<Moderator> go ahean Annie.
<Pen in FL> "?"
<Monica> ?
<annie> Anxiety in my case, seems to affect my ability to sleep. I keep thinking about different things
   relating to my illness
<annie> what will happen, how I feel, what lies ahead, etc.
<annie> my doctor prescriped half a caplet of xanax each night and it really does help
<Moderator> Welcome Denis and Shirl
<Kingman Strohl> Anxiety is often there even if the problem isn't acute. Relaxation techniques, music,
   knitting, etc. are "behaviroal alternatives.
<Moderator> Annie, do you have a follow-up?
<annie> no, thank you very much.
<Kingman Strohl> Use of medications like Xanax can help temporarily, but if used every night there
   occurs tolerance. The drug seems not to work as well.
<Moderator> Pen, you are next. Go ahead.
<Margaret> ?
<Pen in FL> Wondering if not being able to go to sleep at night is hand in hand with the PH
<Roberta in CO> <Roberta> ?
<Pen in FL> I just can't get to sleep so stay up until maybe 2 a.m.
<Kingman Strohl> Insomnia is already common in people with chronic illness. The calcium channel
   blockers can interrupt sleep. Prednisone taking orally is a great sleep inhibitor.
<Kingman Strohl> Whether PH is specific for insomnia I can't tell.
<Moderator> Pen, do you have a follow-up?
<Pen in FL> No for now until I get used to this chat thing.
<Moderator> Monica, you are next.
<Monica> I seem to have sleeplessness on a monthly basis for about 6 or seven days. Could this be
   associated with my period? It seems to occur the week before, most of the time.
<Moderator> Hi Joan
<Kingman Strohl> Your preference to go to sleep at 2am may have a brain basis. Teenagers have this
   tendency and a tendency to prefer late sleep and sleeping in does run in families.
<anneinvermont> anneinvermont "?"
<Kingman Strohl> Sleep and monthly cycles and sleep during and persisting after meonopause is not
   getting alot of attention. There is an influence of sex hormone...
<Kingman Strohl> Sleep Apnea is also more common in the later times of the month when progesterone
   levels fall.
<Moderator> Monica, do you have a follow-up?
<Monica> No, thank you
<Moderator> Margaret, you are next.
<Margaret> When i fall asleep during my afternoon nap, I often have a shallow sleep and wake up with
   a shock running up my spine as if I am being electrocuted. Do you know how I can avoid this sleep
   disturbance?
<Moderator> Welcome, memiufan
<Kingman Strohl> There are a couple of things that come to mind. There are those starts that occur at
   sleep onset, called hypnic jerks, which can be painful tosome and quite startling to others. There are
   also positional issues, thinking that you might sleep differently or in a different place in the afternoon
   than at night. Sorry I don't have theanswer.
<Moderator> Margaret, do you have a follow-up?
<Margaret> N
<Margaret> No
<Moderator> Roberta, you are next.
<Roberta in CO> <Roberta> My problem is not in getting to sleep initially, but once I have to get up for
   the bathroom I have a heck of a time getting back to sleep.
<Kingman Strohl> Is there a problem with movement when these shocks occur?
<Margaret> No
<Margaret> I sleep on my side with one leg stretched out in front of the other.
<Denis> ?
<Kingman Strohl> Roberta. This is pretty common. It can become a habit, or it may be a manifestation
   of the idea that there are molecules that help you go to sleep that are different from those that keep
   you awake or wake you up.
<Moderator> Roberta, follow-up?
<Roberta in CO> <Roberta> Interesting about the CCB & sleep disturbance. Would it make a
   difference taking it in the morning instead of the evening?
<Kingman Strohl> One can counter this by trying to sleep less for a few nights, getting so tired that you
   sleep through things. Also watch out for how much you drink before you go to bed.
<Moderator> Welcome Sharon.
<sharon> hello
<Moderator> Welcome Linda
<Moderator> Annie, go ahead
<annie> I didn't have a question...was it the other annie?
<Moderator> ok
<Moderator> Denis, go ahead
<Denis> My heart beat keeps me awake for the first couple of hours. Is their any way to lessen this?
<Shirl> ?
<Pen in FL> <Pen> ?
<Moderator> Sorry, Anne. I see it was you that had a question. Once this question is finished you will
   be next
<Kingman Strohl> Tough one. there may be a positionin which it might not bounce against the chest
   wall. If you hear your heart beat then you might try music. Then I guess youcould use some
   relaxation and body imaging . Like, probably good that you hear it?
<Moderator> Denis, follow-up?
<Denis> It's not so bad on my right side but, it takes two or three hours to calm down enough for me to
   sleep.
<Kingman Strohl> It's the calming down, then. Try some music or white noise as a distractor. Read a
   book if you can't get to sleep in 20-25 minutes.
<Moderator> Anne, go ahead.
<anneinvermont> With both restrictive and obstructive lung diseases I sleep about two hours a night.
   Breathing, pain chest, lungs, ribs keep me awake remainder. Any suggestions how to stop this and
   improve sleep time
<Kingman Strohl> Nothing easy tonight...
<Moderator> This is a good crowd!!!
<Moderator> Welcome Fay
<Moderator> Welcome Mimi
<Moderator> Dr. S is in the middle of a question, for those of you who just joined us.
<Kingman Strohl> I think that youshoudl inventory your sleep needs. Are you sleepy during the day? If
   not you are getting enough sleep. If sleep is a distractor (and it is a time in which aches and pains are
   less), then try distractors like music or vibration. Certainly gettinghte best pain releief is importatn.
<Moderator> Anne, do you have a follow-up?
<anneinvermont> what do I do about pain when I am chemically sensitive.
<Kingman Strohl> Imagery. Vibration. Pain specialist in regard to local treatments. These are ideas, not
   knowing you well..
<Armond & Carol> Shirl, You're next. Michael will be right back
<Shirl> This should be easy Doctor. I use CPAP with 02 at 5 L and wear the Adams Circuit headgear.
   The problem I have is that my nose gets "stuffed up" and blocked (even though I use saline
   spray)during the night and wakes me up. Any suggestions?
<Kingman Strohl> Nasal obstruction with CPAP is relatively common (25-30% of patients).
   Humidification. Sometimes medications like atrovent or nasal steroids. Are helpful. In really tough
   cases I consult an ENT person.
<Moderator> Shirl, follow-up?
<Shirl> no since I'm on Flolan can't use that stuff......
<Moderator> Pen, you are next
<Pen in FL> would a sleep study be of any use for me when I seem to have insomnia and maybe not
   sleep apnea. I also get up several times per night and can't get back to sleep.. Should I ask for a study
   at Mayo next trip and also if a CPAP machine would be good for me with this problem. This is all
   pretty new. but I've had bad sleep habits all my life
<Kingman Strohl> The nasal meds are all topical. But check with your doctor.
<Kingman Strohl> A sleep study for insomnia is not generally the first thing to do. The Mayo group has
   some experts on insomnia (Dr. Peter Hauri) and others. Sleep apnea can be accompanied by
   complaints of insomnia but there usually are other hints.
<Moderator> Pen, do you have a follow-up?
<Pen in FL> What do I look for and what do I ask for up there.
<Kingman Strohl> If you have bad sleep habits, this might be something to work on. There are some
   books in the local public library that can start the process.
<Moderator> Memiufan, you are next. Go ahead.
<Kingman Strohl> As for the Mayo, start with your regular doctor, but if you have read something
   beforehand you will know how good the answer seems.
<Moderator> If there are other questions, please send a "?"
<memiufan> Dx' d with PPH & Sleep Apnea. Pph specialist said forget about sleep apnea. Is there a
   conflict there?
<Margaret> ?
<Kingman Strohl> Without knowing your numbers on the sleep study, that might be appropriate. but I
   would ask for reasons for not trying something about sleep apnea if it bothers you with sleepiness or
   snoring or if there is alot of low oxygen at night. He might say not to worry if you are not sleepy, not
   concerns about snoring, and are being treated with oxygen.
<Moderator> Memiufan, do you have a follow-up?
<memiufan> Dips to low 90'. I guess it's too mild to treat. Thanks.
<Pen in FL> ?
<Kingman Strohl> Follow-up?
<Moderator> Margaret, you are next.
<Margaret> I sleep a lot 8-10 hours per night, but never feel rested. I have 2-3 half hour sleeps as well.
   Is there something I can do to help me feel rested?
<Kingman Strohl> I would ask about plans to follow-up. One idea is repeat an oxygen saturation profile
   if things change or in 6-12 months to see that it is still above 90%.
<Kingman Strohl> Margaret...
<Margaret> During sleep?
<Margaret> While awake I am 98%.
<Kingman Strohl> You seem to have an increased sleep need. This can mean excessive daytime
   sleepiness or it could be a variant. Questions to ask yourself? Is there something that interrupts my
   sleep? like leg jerks, ro snoring. Do I fall asleep even when I do not want to. Talk to you doctor.
<Moderator> Margaret, do you have a follow-up?
<Margaret> Thank you, no.
<Moderator> Pen, you are next.
<Kingman Strohl> The previous was about the PPH and sleep apnea. Margaret gets the sleepiness
   response.
<Pen in FL> My oxygen level goes straight into the low 80's once I get to sleep. Is this a sign of a sleep
   problem? I am on O2 24/7.
<Margaret> ?
<Kingman Strohl> CAuses for a low oxygen during sleep are either an increase in CO2 (breathing very
   shallowly during sleep) or a mismatch in blood flow to ventilation to the lungs. The latter can be
   helped with more oxygen. The former needs a different approach.
<Moderator> Pen, do you have a follow-up?
<Pen in FL> yes, what is the different approach
<Kingman Strohl> One has to look for muscle weakness especially inthe breathing muscles, a higher
   than normal value of CO2 during wakefulness, and a need to breathe with bilevel ventilation during
   sleep. Remember I am not making a diagnosis here.
<Moderator> Armond, you are next. Then Margaret. Go ahead Armond.
<Armond & Carol> Do you feel that even the mild desaturation that occurs during sleep in PH patients
   without sleep apnea affects quality of sleep. Particularly in terms of frequent short awakenings?
<Moderator> Welcome me
<Moderator> If you have a question, please send a "?"
<me> hello thanks
<Moderator> Dr. Strohl is in the middle of a response
<me> ok
<Kingman Strohl> No studies in patients. If I take a healthy person to altitude people wake up because
   of breathing rather than hypoxia. I can make a person hypoxic during sleep and they won't wake up
   until a saturation of 85% or less. One usually wakes up from respiratory stimuli becasue fo breathing
   funny (chest wall moving differently) or increased CO2.
<Moderator> Armond, do you have a follow-up?
<Moderator> 'n you, welcome.
<Armond & Carol> thank you. you've cleared up exactly my question about high altitude sleep
   disruption
<Moderator> Margaret, go ahead.
<Margaret> My sph was caused by damaged heart valves, I have been tested for sleep apnea and was
   told that I don't have it. Is there a possibility that I could have developed sleep apnea in the last couple
   of years?
<Kingman Strohl> Maybe. But you probably would have developed new symptoms too.
<Margaret> Such as?
<Kingman Strohl> Snoring and pauses in breathing during sleep. Restless sleep. Daytime sleepiness.
   maybe systemic hypertension.
<Moderator> Any more quesions? We have time for just a couple more.
<Armond & Carol> more quMichael will be right backestions.
<Margaret> ?
<Armond & Carol> Margaret go ahead
<Margaret> I often suffer from numbness around my mouth, is this caused by too my CO2?
<Margaret> too much CO2?
<Kingman Strohl> The firstthing that comes to mind, as a respiratory person, is a low CO2 level.
   Therea re other things that might cause this like calcium flux. But not too high a CO2 level. Have you
   kept track of this and told your doctor how often and when it happens?
<Margaret> Yes
<Diana> ?
<Moderator> Diana, go ahead. you will be the last question
<Diana> DR. K , Do they have a PH clinic at UH?
<Kingman Strohl> The people who see PH at University Hospitals of Cleveland on a routine basis are
   Paul Lange M.D. and now Rana Hejal M.D. We don't have a designated PH clinic, however.
<Diana> Thamk you
<Moderator> Diana, follow-up?
<Diana> no thanks
<Moderator> That's all folks! Thanks Dr. Strohl!! Thanks Everyone!!!
<Moderator> The entire transcript will be posted on PHCentral's chat page soon.
<Kingman Strohl> Thank you. sleep weel and have a better tomorrow.
<Moderator> Don't forget to vote in the "treatment poll" on the PHCentral home page.
   http://www.phcentral.org
<Moderator> The room is now open for a free form chat!
<Margaret> Thank you
<Armond & Carol> thanks dr S, and all who attended