Topic: PH and Sleep Disorders 
Date: July 24, 2000 
Guest: Dr. Kingman Strohl, University Hospitals of Cleveland, Department of Pulmonary and Critical Care Medicine 


<Moderator> ***ATTENTION*** 
<Moderator> ***ATTENTION*** 
<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 Sleep Disorders/Sleep Apnea
<Moderator> ***The moderator today is Michael Szczepkowski 
<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.
<Moderator> ***OK, we are ready to begin!!
<Moderator> *** If you have a question...
<Skipper M. in Texas> ?
<Moderator> ***please type and send a "?"
<Moderator> Skipper go ahead
<Jean> ?
<Monica> ?
<Skipper M. in Texas> Are folk of larger physical stature any more susceptible to sleep 
apnea than the folk of lesser stature..if so, why so?
<Kingman P.Strohl M.D> If by stature you mean height, there is no good correlation with 
sleep apnea. If you mean weight according to height, then there is a good correlation 
with weight...
<Poacher..jo> My husband says that I run all night. I have trouble getting asleep and 
staying asleep all night.,sometime waking up about 4AM wide awake. I have been 
taking klonothin off and on and sometimes it helps and sometims not. Should I be seeing 
a doctor for my problem?
<Moderator> Poacher, please wait.
<Poacher..jo> OK
<Moderator> Poacher, I will add you to the list
<Kingman P.Strohl M.D> The metric is Body mass index, a metric that combines weight 
and height. The problem with weight is that the neck gets heavy and the belly poushes 
up against the chest..
<carrie> "?"
<Sandy in MN> ?
<Kingman P.Strohl M.D> both seem to act to produce sleep apnea. There are some other 
mechanisms as well.
<Moderator> Skipper, do you have a follow-up question?
<Skipper M. in Texas> A new study I read about this past week indicated slender folk 
undergo some different aspects of airway passage obstruction than do larger folk. Do 
you have any take on that study?
<Kingman P.Strohl M.D> We have evidence that you can get slee apnea from not only 
obesity, but also jaw size, respiratory control (response to carbon dioxide), and by a 
combination of these factors.
<carrie> i am the "poster girl" of sleep disorders: narcolepsy; nonhyperactive ADD, very 
recent sleep apnea and more recently, insomnia.
<Moderator> Jean, you are next.
<Jean> Should someone with PPH get a sleep study or are there specific symptoms we 
should look for before considering a study?
<carrie> sorry, i meant to just pretype my question!!
<Kathleen> ?
<Kingman P.Strohl M.D> At the present time, I don't think that all those with pulmonary 
hypertension need a sleep study, unless there is some evidence by history (heavy 
snoring, observed pauses during sleep).
<Moderator> Jean, follow-up question?
<Jean> no, thank you
<Moderator> Monica, you are next.
<Monica> Can someone develop sleep apnea if they sleep on their side or stomach?
<Kingman P.Strohl M.D> Sure. but it seems as if those who have real problems with 
sleep apnea have it in most all positions. It may be worse on the back, but still present on 
the side.
<Moderator> Monica, do you have a follow-up?
<Monica> Is there a number one indicator that you may have sleep apnea?
<Kingman P.Strohl M.D> Well, everyone will have an apnea now and then. the reason to 
treat the sleep apnea is when it produces problems, like excessive daytime sleepiness, or 
cardiovascular problems, or annoying others, perhaps.
<Moderator> Poacher, you are next.
<Poacher..jo> This is KaY HIS WIFE, and I am told that I run all night. AM very tired 
when I get up. Taking Klonothin once in awhile and sometimes helps and sometimes not.
<Kingman P.Strohl M.D> "Running all night" can be a sign of "restless legs syndrome" in 
which there are leg movements all night accompanied by daytime funny feelings in the 
legs...
<Kingman P.Strohl M.D> A related problem is called periodic leg movements, a condition 
where there are no daytime symptoms. These can produce sleepiness by interrupting 
sleep. The drug you are on is one that has been sued to treat these disorders.
<Moderator> Kay, do you have a follow-up?
<Poacher..jo> no thank you.
<Moderator> Monica, your question?
<Moderator> Carrie, sorry.
<dick> ?
<Moderator> Carrie, you are next.
<carrie> does ph tend to erase the oversleeping types of sleep disorders, and then produce 
insomnia?
<Moderator> Moderator did not get enough sleep:-)
<Kingman P.Strohl M.D> Not that I know of.
<Moderator> Carrie, do you have a follow-up?
<carrie> follow throughyes
<carrie> should i keep taking ritalin, even though i now have insomnia, and trouble sleeping 
at night and napping?
<Kingman P.Strohl M.D> Ritalin is a drug that can produce insomnia. you have to be 
careful about its duration of effects. Ritalin has the side-effect of hypertension. Do you 
know if it affects pulmonary artery pressures?
<carrie> it was cleared as safe by the Myo clinic.\
<carrie> i took it for 10 years for the narcolespy and add.
<carrie> ADD
<Kingman P.Strohl M.D> I think that you ned to go over the use of Ritalin in regard to 
your sleep wake cycle. Insomnia work-up can be found on the National Center for Sleep 
Disorders Research webpage at the NIH.
<Moderator> Sandy, you are next.
<carrie> thank you very much.
<Sandy in MN> Is there a correlation between OSA and PPH? I hear yes and no. I was 
diagnosed with OSA 7 years ago, and use a CPAP, now the PPH. Or am I just lucky to 
have the body type, as does my brother who also had the OSA.
<Kingman P.Strohl M.D> OSA is associated with pulmoanry hypertension although we 
cannot predict who might get it or why only certainpeople get it. Treatment of OSA is 
supposed to stop progression or reduce pulmoanry artery pressures...
<Kingman P.Strohl M.D> The diagnosis of PPH after OSA and its treatment would be 
complex one, probably requiring evidence for a normal pulmoanry artery pressure after 
OSA treatment.
<Moderator> Sandy, do you have a follow-up?
<Sandy in MN> So, what can I do to help the PPH at this point?
<Sandy in MN> Sorry, I guess you already a answered that.
<Kingman P.Strohl M.D> Know you pressures, and collect all the information you can on 
treatments, and then make a decision to treat the pulmonary artery pressures even while 
treating the OSA. That is an opinion not based upon an examination or specific 
knowledge of you..
<Moderator> Kathleen, you are next.
<Kathleen> Are there any % figures of how many with PH have it secondary to Sleep 
Apnea? How would that be identified?
<Sandy in MN> Thank you for the information.
<Kingman P.Strohl M.D> There are few collections of a great numberof patients. There 
is one family medicine practice that found that 30% of people with pulmonary artery 
pressures of about 30 systolic had OSA or another form of sleep apnea.
<Moderator> Kathleen, do you have a follow-up?
<Kathleen> No. Thanks.
<Moderator> Dick, you are next.
<dick> How often should the CPAP settings be checked and how often should the wearer 
be reevaluated to make certain that a change is not needed in the pressure?
<Moderator> Anyone else with a question, please send me a "?"
<Kingman P.Strohl M.D> We check the pressures about every 6 months for a year and 
then every year. I do not do a repeat sleep study unless theperson begins to snore 
(again) or gets sleepy and I can't figure out why.
<Joyce Rahn> ?
<Debbie W> Dr . Strohl, my mother was diagnosed 3 years ago with PPH. I have sleep 
apnea (on CPAP) and took Redux for several months a few years ago. How much do 
these factors increase my chances of developing PH?
<mimi> ?
<Moderator> Dick, do you have a follow-up?
<Moderator> Debbie, I will call on you afer Joyce.
<dick> No. and Thanks a lot.
<Moderator> Joyce, your question?
<carrie> ?
<Joyce Rahn> I've been using CPAP for a couple of years ago and I have never felt like 
there is enough oxygen flowing through? I've never had to use the ramp button is that 
normal?
<alex> ?
<Kathleen> ?
<Kingman P.Strohl M.D> CPAP is not oxygen, just air. Once it is on the nose and sealed 
there should be no more flow. if you feel you can't get enough air there could be a 
problem. Have the machine checked by the home care provider...
<Kingman P.Strohl M.D> As for the ramp, many just disregard it after a few weeks.
<Moderator> Joyce, do you have a follow-up?
<Joyce Rahn> unsure at this time
<Joyce Rahn> will requestion after I've thought about it
<Moderator> Debbie, you are next.
<Shirley--Colo.> <shirley>I've been told after PPH diagnosis that I have sleep apnea, was 
never titrated with a C-PAP mask. My pulmonologist told me to just kick the 02 up a L 
at night. Am now having a harder time sleeping than ever, what would you suggest?
<Debbie W> My mother was diagnosed with PPH 3 years ago. I have sleep apnea and 
took Redux for several months a few years ago. How much does this increase my 
chances of developing PH?
<Moderator> Shirley, I will add you to the list.
<Kingman P.Strohl M.D> I can't be sure and I do not know if there are studies, but it 
seems like having two causes for pulmoanry hypertension is more problematic than one.
<Moderator> Debbie, do you have a follow-up?
<Debbie W> No. Thank you.
<Moderator> Mimi, you are next.
<Joyce Rahn> ?
<Kingman P.Strohl M.D> Follow-up for Joyce. When you have your mask on you should 
be able to take good breaths. The continuous flow should only be a continuous pressure 
when on your face..
<Moderator> Mimi, do you have question?
<mimi> Should I be seeing a difference in sob, and other ph symptoms, after 4 months of 
c-pap?
<mimi> Should I be seeing a difference in sob, and other ph symptoms after 4 months of 
c-pap?
<Kingman P.Strohl M.D> Most often I see an increase in alertness and an increase in 
exercise tolerance. The shortness of breath with sleep apnea is not well understood. If 
you have pulmonary artery pressures that have been high for a long time it may take 
more time for them to reverse.
<Moderator> Mimi, do you have a follow-up?
<mimi> no
<Moderator> Carrie, you are next.
<carrie> my husband felt 100% refreshed after using his C_PAP for a week; I have 
noticed no difference in feeling refreshed in the morning. Does that have any 
significance?
<carrie> i have neither an increase in alertness, not increasing exercise tolerance.
<Kingman P.Strohl M.D> Your question is unclear. Were you treated too?
<carrie> yes with C-PPAP for 6 weeks.
<Kingman P.Strohl M.D> Time to re-group onthe treatment. Review your sleep length. 
Review your diagnosis. Check to see if you had anything else (anemia, asthma, etc.). 
time to review this, although it is said that response can take 6-8 weeks.
<Moderator> Carrie, do you have a follow-up?
<carrie> no, thank you.
<Moderator> Alex, you are next.
<alex> at night, i wake up gasping for breath sometimes, could that be apnea or GERD, i 
have positional apnea so i sleep on my side. thank you.
<Kingman P.Strohl M.D> Could be GERD or sleep apnea. Sometimes we rx for GERD 
and follow-up in 2-4 weeks. It depends upon how often adn what other symptoms.
<Moderator> Alex, do you have a follow-up question?
<alex> the ph doc thinks it's gerd
<alex> thanks no more questions
<Moderator> Kathleen, you are next.
<Kathleen> Does one remain on CPAP therapy forever/indefinately, even if the 
pulmonary artery pressures return to normal range?
<alex> ?
<Kingman P.Strohl M.D> When the pressures go back to normal, then you can try to go 
off of CPAP to see what happens. If you went on CPAP for sleepiness or snoring, you 
will get it back the first or second night off CPAP.
<Moderator> Kathleen, do you have a follow-up?
<Kathleen> No, thanks. This has been very helpful.
<Moderator> Shirley, you are next.
<Debbie W> ?
<Kingman P.Strohl M.D> Kathleen, tell you doctor when you do try to go off.
<Moderator> Shirley, do you have a question?
<Kathleen> I certainly would do that. Thanks.
<Moderator> OK, Joyce, you are next, go ahead.
<Joyce Rahn> My first sleep test showed that I had an "episode" running a little more than 
30 an hour. My second test showed that the CPAP had reduced that down to less than 
12, but I still was not sleeping soundly. They were unable to determine a setting which 
would eliminate the episodes. My third test I'm still waiting on the results from. Just 
before the 3rd test they dx PH or SPH with pressures of about 80 at rest at 115-120 
with minimal exertion. I'm now on flolan. I'm on 5 ml o2 24/7, but often feel I just can't 
sufficient breath. I use an adapter to tie the 02 into the CPAP. I've just wondered if the 
SA was an accurate diagnosis or if the previously undiagnosed PH was creating a false 
SA dx? thank you
<Moderator> Shirley, let me know if you still have a question.
<Kingman P.Strohl M.D> I guess its possible that the PH produced some respiratory 
instability. I would have to know more about your case and the test results before 
making a better guess.
<Moderator> Joyce, do you have a follow-up?
<Joyce Rahn> Yes, my husband hates the 
<Joyce Rahn> noise of the CPAP any suggestions?
<Joyce Rahn> Besides dumping the husband, I'm quite attached to him!
<Kingman P.Strohl M.D> Ah, the noise. You can use an extension hose for the machine. 
There are masks that are quieter too. Of course, if he snores....
<Joyce Rahn> Yes, he snores, but I sleep through him when I do sleep.
<Joyce Rahn> Thanks for the suggestion of the extension hose, I will ask my home 
provider about it. No more questions. Thanks
<Kingman P.Strohl M.D> then you can diagnose him. Usually the noise is white noise. But 
I would go to the home care company and look over extensions and masks.
<Moderator> Alex, you are next.
<alex> how often should a person have a sleep study? only once or yearly?
<Kingman P.Strohl M.D> A sleep study is done to diagnose a problem, so I guess that 
depends if the first one was useful. sometimes one needs more than one sleep study to 
make a diagnosis and treat effectively.
<Moderator> Alex, do you have a follow-up?
<alex> no thank you 
<Moderator> Debbie W, you are next.
<Moderator> Anyone else with a question, please send a '?"
<Debbie W> How is a re-evaluation done on c-pap pressures? Another sleep study? I'm 
still feeling tired and sleepy in the mornings.
<Kingman P.Strohl M.D> I'll tell you what I look for. If a person begins to have trouble 
again, I review sleep habits, sleep length, and hisotryof snoring and machine use. I check 
the machine prressures and the mask. If these do not seem to be a probelm..
<Kingman P.Strohl M.D> then I increase the pressure 2 cmH2O. I recheck in a couple of 
weeks and then may do a sleepstudy. There usuually is something happnening, most 
often something simple.
<Moderator> Debbie, do you have a follow-up?
<Moderator> Anyone else with a question, please send a '?"
<ShirleyJewett> ?
<Debbie W> No thanks..
<Joyce Rahn> ?
<Moderator> Shirley, you are next.
<ShirleyJewett> If a person with PH has a lung transplant, does the sleep apnea go away?
<Kingman P.Strohl M.D> I don't konw about lung transplants. Those with cardiac 
problems and sleep apnea (central type) who undergo a heart transplant have the sleep 
apnea get better.
<Moderator> Shirley, do you have a follow-up?
<ShirleyJewett> If a person with sleep apnea is in the hospital and has no access to their 
CPAP machine what happens to them?
<ShirleyJewett> Stroke??
<Kingman P.Strohl M.D> Usually I tellpatients to bring their machine with them. The 
hospital CPAP equipment is like your equipment, as a hospital pillow is like your pillow.
<Moderator> Joyce, you are next.
<Joyce Rahn> Would you like me to retype Shirley in Co question in case she doesn't 
understand how to do it?
<Moderator> Yes, please.
<Moderator> Thank you.
<JeanneB> ?
<Kingman P.Strohl M.D> One night off of CPAP will make you sleepy but I know of no 
insatnce of stoke. The problem is during post-operative care, when you need CPAP to 
help get extubated..
<Joyce Rahn> Shirley -- I've been told after PPH diagnosis that I have sleep apnea, was 
never titratated with a C-PAP mask. My pulmonogist told me to just kick the 02 up a L 
at night Am now having a harder time sleeping than ever, what would you suggest?
<Kingman P.Strohl M.D> Oxygen is a second line treatment for obstructive sleep apnea. I 
would re-ask about CPAP. perhpas ask for a copy of the sleep study report.
<Moderator> JeanneB, you are next and the last for tonight.
<Moderator> JeanneB, do you have a question?
<JeanneB> If sleep studies showed idiopathic hypersomulance and now a diagnosis of PH 
should the studies be done again?
<Kingman P.Strohl M.D> The sleep study would have shown no indicationof something 
disturbing sleep, but I assume that the daytime studies (multiple sleep latency test) 
showed sleepiness. Withthe finding of PH, some doctors suggest a second sleep study 
because there are reports of false negative sleep tests for OSA and...
<Kingman P.Strohl M.D> others suggest repeating the study with measurements of 
esophogeal pressure to rule out upper airway resistance syndrome.
<Moderator> JeanneB, do you have a follow-up?
<JeanneB> There was no apnea at that time, thanks.
<Moderator> Thanks Everyone, Thanks Dr, Strohl!!
<carrie> Thank you, Dr. Strohl. You have been most helpful. Thanks, Michael for a neat 
job, as usual.
<Moderator> We will put up the chat log shortly.
<dick> Thanks, Dr. Strohl. Very informational and helpful. See you at the luncheon next 
month.
<Skipper M. in Texas> Thanks, Moderator, and Dr. Strohl.
<Dorthea> Thank You Dr Strohl
<Joyce Rahn> Thanks
<Moderator> Good Night!
<alex> thank you dr and moderator
<Moderator> HI lblumken
<alex> hi ilblumken. welcome to phcentral
<lblumken1@aol.com> lenore
<Moderator> we just finished the guest chat.
<Moderator> You are welcome to...
<Moderator> stay and chat with everyone though.
<lblumken1@aol.com> I am so sorry I missed it. I just found the web site.
<alex> how is everyone doing tonight?
<Moderator> Hi Corey
<Armond> There will be others, Lenore
<alex> lenore, you can see the transcripts of the chats, probably in the next few days i 
would guess
<mimi> ?
<barbara[maine]> pretty good. sorry i missed most of the guest chat
<alex> i know ,me too barbara
<Moderator> Mimi, we are done with the chat, sorry.
<lblumken1@aol.com> When is the next one?
<Joann SA> I enjoy these chats very much.I find them extremly informative
<Kathleen> I`m fine. I really appreciate these chats---I benefit from answers to everyone 
else`s questions, well as mine.
<lblumken1@aol.com> Are you all patients? or caregivers?
<alex> i'm a patient on flolan for nearly 2 years
<Moderator> lblumken, not sure. We will post it. Are you a member of PHFriends ?
<Moderator> Listserv?