A Partner in Sleep Medicine

By Jennifer Webster
Friday, November 11, 2016

Referring physicians will find common health issues improve or resolve with proper sleep treatment guided by experienced sleep medicine physicians at WellSpan Health.

A technician places sensors on the patient to collect data during the sleep session that enables physicians to make an accurate diagnosis.

WellSpan Health cares for the whole patient. That’s why they promote services that address a wide variety of concerns, and why they pay careful attention to relationships — between physician and patient, and between referrer and specialist.

A case in point is WellSpan’s sleep centers, which offer sleep medicine to patients of all ages. WellSpan’s pulmonary and sleep medicine physicians diagnose and treat commonplace and rare sleep concerns, all at locations that are accessible to patients across South Central Pennsylvania.

“We have five labs,” says Richard Murray, MD, pulmonologist and Medical Director, WellSpan Gettysburg Hospital Sleep Center. “We have eight sleep pulmonologists at WellSpan York Hospital Sleep Center in Dover and two sleep pulmonologists in Gettysburg. All are also board certified in sleep medicine.”

Dr. Murray adds that 2,700 studies were performed in Dover during this past fiscal year that ended July 1. WellSpan also operates sleep centers in Lebanon, Lancaster and Denver, PA.

Sleep Awareness

Sleep interacts with almost every bodily system — circulatory, pulmonary, immune, endocrine, even psychological — in complex ways. A patient’s complaint of fatigue may have far-reaching implications; conversely, unreported sleep troubles may account for conditions that have been diagnosed but are proving resistant to treatment.

Sheela Ahmed, MD, pulmonologist with WellSpan Pulmonary and Sleep Medicine and board-certified in internal medicine, sleep medicine and critical care, notes that physicians are becoming more aware of how sleep problems, especially sleep apnea, impact health. Endocrinologists and cardiologists are now referring patients for sleep studies, Dr. Murray adds.

“Patients are commonly not aware they have sleep apnea,” Dr. Ahmed says. “When you are awake, you don’t have issues with sleep apnea, so it’s unsurprising you don’t report it. But awareness among physicians is increasing. We are undertaking outreach programs to educate primary care providers, cardiologists and anesthesiologists — these are the settings in which we want sleep apnea to be identified and evaluated.”

Skilled Diagnosis

To diagnose sleep disorders, WellSpan offers standard polysomnography as well as a multiple sleep latency test, also known as a “nap study,” to detect narcolepsy. Other tests, such as a titration polysomnogram, determine the amount of air pressure needed for continuous positive pressure airway (CPAP) treatment. The maintenance of wakefulness test assesses whether a patient such as a driver or pilot is likely to fall asleep. And a wearable actigraphy device is used to monitor sleep behaviors in the home.

Testing is conveniently offered in Adams, Lancaster, Lebanon and York counties.

“Right now, the labs all perform basic sleep studies and a CPAP titration study,” Dr. Murray says. “All labs are doing more home sleep studies in selected patients. If a patient does not have COPD or cardiac problems, and there isn’t suspicion of a less common condition such as narcolepsy — just a straightforward high probability of sleep apnea in an otherwise healthy young person — we can perform a home study through any of the labs.”

Board-certified pulmonologists or sleep medicine physicians interpret the studies and make treatment recommendations.

Problems Common to Rare

As Dr. Ahmed notes, sleep apnea is among the most common concerns in sleep medicine today.

“In patients older than 65, more than half will have some degree of sleep apnea,” she says. “There are well-developed tools, including questionnaires that can be used to screen for the condition. We also have an instrument called ApneaLink at some of our family practices. It can be used as a screening tool or, in some cases, to actually diagnose sleep apnea.”

Dr. Ahmed adds that undiagnosed and untreated, sleep apnea increases chances of hypertension, cardiac arrhythmias and cardiac events such as myocardial infarction and congestive heart failure. If patients have these conditions to begin with, sleep apnea worsens their control of them.

One of the sleep study rooms at the WellSpan Gettysburg Hospital Sleep Center.

In the postoperative setting, sleep apnea patients tend to have delayed recovery from anesthesia. These patients’ oxygen levels tend to drop and they retain carbon dioxide gas when given anesthesia or sedation, or narcotics for pain management. When a patient has this type of trouble coming out of anesthesia, they can end up in the ICU.

“Knowing ahead of time that a patient has sleep apnea can help the anesthetist plan for the management of these issues and keep patients safe,” Dr. Ahmed says.

Treatment for sleep apnea typically consists of a CPAP device that keeps the airway open during sleep. Dental appliances may serve a similar function. Occasionally, surgery is recommended to remove upper airway obstructions. Lifestyle changes, such as weight loss and alcohol cessation, may lessen sleep apnea as well.

Another problem pulmonary and sleep medicine physicians treat is narcolepsy, in which patients fall asleep and enter REM sleep very quickly. Narcolepsy is typically managed by medications and sleep hygiene measures such as scheduled naps. It often occurs independently, but can accompany sleep apnea, Dr. Ahmed says.

WellSpan’s sleep centers also address pediatric sleep disorders, including sleep apnea, parasomnias, night terrors and bed-wetting. Academic and behavioral problems may be linked to childhood sleep disorders, which are confirmed through a patient history and polysomnography. In fact, sleep problems may be incorrectly diagnosed as attention deficit/hyperactivity disorder. In children, enlarged tonsils and adenoids may be the cause of sleep apnea, and sleep apnea may resolve with removal of enlarged tonsils and adenoids, Dr. Ahmed says. Pediatric sleep studies are offered at WellSpan Ephrata Community Hospital, which is accredited by the American Academy of Sleep Medicine.

How to Refer a Patient

Patients need a referral to make an appointment at WellSpan’s sleep centers.

“We collaborate closely with primary care medicine providers,” Dr. Murray says. “Ordering providers have options: They can send a patient to us to perform a consult and then a sleep study, or they may send a patient with obvious sleep apnea symptoms directly for a sleep study. They can refer that patient to any lab he or she chooses. If the study does show sleep apnea, the referring provider may choose to manage the patient and order the CPAP equipment for them. Or, we can consult with the patient and manage the CPAP. For many providers, that’s a good option. They can order the study — often a home study, which is most cost-effective for the patient. If it’s normal, they’ve usually ruled out sleep apnea. If it’s positive, they can manage the patient or we can, depending on their comfort level.”

Sometimes a home study may result in a false negative because these studies tend to overestimate total sleep time, adds Dr. Murray. If a high clinical suspicion for sleep apnea remains, a follow-up study at a sleep center is usually recommended.

WellSpan’s physicians stay in contact every step of the way, keeping primary care providers updated about their patients’ progress.

To make a referral in Adams County call 717-339-2790; in Lancaster County call 717-738-4334; in Lebanon County call 717-272-8173; and in York County call 717-851-2465. To learn more, visit WellSpan.org.