Sleep Apnea

[TWR]

If diagnosis of sleep apnea is made andappropriate CPAP initiated, would you also give a sleep aid ie: Lunesta?

[Guest hubbardtim48]

I am just a student and a resp. therp., but if it was me doing the work up then I would make sure appropriate CPAP/BIPAP settings with or without O2, type of mask (nasal mask, nasal pillows, full face, etc.), sleeping habits before bed (drinking ETOH before bed/or too much water, eating before bed, too much stimulation (TV etc..)). I would look for those types of things first and see if the patient could fall asleep comfortably with the CPAP/BIPAP and if the patient has changed their sleeping habits then I might consider those types of things. I just had a talk with someone yesterday about patients and family on sleep aids and a few of them commented on how it made the patient or their family member crazy etc..One story told by a sleep tech. (RRT) at my facility was a guy took a sleep aid before his sleep study (his third study trying to get a sleep) so the doctor gave him a sleep aid and he was admitted to the ER without knowing what happened to him. They showed him the video and the sleep tech said he was pulling the EEG leads off and spitting on himself and swinging at things in front of him, etc.. Security had to be called cause he was crazy and she was said it seemed like he was on acid and was having an acid trip. So that is my reservation against just giving people sleep aids. I would change habits first then use that as my last resort.

[bradtPA]

Lunesta would be a good choice. While CPAP helps with sleep efficiency, sleep architecture is still fragmented. Lunesta works on three GABA receptor sites and has an indication for long term use. Also to be considered is modafinil, as it can further increase efficiency and reduce excessive daytime sleepiness.

[Guest hubbardtim48]

Sleep architecture may not be the problem, it could just be the secondary problem stemmed from the lack of REM sleep due to OSA. If I was the provider I would never prescribe someone with OSA a sleep aid without trying the above things I mentioned.

[ventana]

I actually do not write sleep meds - great hand out fromthe Canadian sleep society that sleep is a habit

http://www.canadiansleepsociety.com/pdf/brochure/normal_sleep.pdf

 

need to exercise and have good sleep hygiene and not just take a pill

 

I work with people on this issue and the benefits of getting people active and movingand eating healthy and decreasing soda and coffee works better then any med

 

 

DO NOT GIVE BENZO's as a sleep aide.... evil

[Joelseff]

Lunesta would be a good choice. While CPAP helps with sleep efficiency, sleep architecture is still fragmented. Lunesta works on three GABA receptor sites and has an indication for long term use. Also to be considered is modafinil, as it can further increase efficiency and reduce excessive daytime sleepiness.

 

How about Silenor (doxepin)? Non narc sleep aid. I have rxd it for insomnia pts with good results. No daytime somnolence and non habit forming. Mech of action is unknown but thought to be a H1 blocker

 

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[bradtPA]

I have not a lot of experience with Silenor, so I can't comment there. Rozerem, however, never seemed to be of benefit when I tried it for OSA patients.

[bradtPA]

Sleep architecture may not be the problem, it could just be the secondary problem stemmed from the lack of REM sleep due to OSA. If I was the provider I would never prescribe someone with OSA a sleep aid without trying the above things I mentioned.

 

I have had numerous discussions On the topic with some talented pulmonologists. If Lunesta is good enough for the chief of pulmonary medicine at Walter Reed, it's good enough for me ;).

[Guest hubbardtim48]

That is great you have lots of trust in the chief, but my concern is the patient and how it affects one's body. Just because it puts them to sleep may not be the best thing for their body. I don't see a reason to start a sleeping aid with some one that has OSA. If you fix/treat their OSA there is not need for a sleep aid. I have seen it a million times and sleeping habits are the main cause of restlessness. I don't like pumping pills into someone unless I have used every resource that I can. Lunesta will NOT FIX OSA, so why sedate the crap out of them? Does it make you feel better that they are "sleeping" when they aren't really sleeping, they are just sedated....makes no sense to me.

[bradtPA]

That is great you have lots of trust in the chief, but my concern is the patient and how it affects one's body. Just because it puts them to sleep may not be the best thing for their body. I don't see a reason to start a sleeping aid with some one that has OSA. If you fix/treat their OSA there is not need for a sleep aid. I have seen it a million times and sleeping habits are the main cause of restlessness. I don't like pumping pills into someone unless I have used every resource that I can. Lunesta will NOT FIX OSA, so why sedate the crap out of them? Does it make you feel better that they are "sleeping" when they aren't really sleeping, they are just sedated....makes no sense to me.

 

Tim,

 

Unfortunately, you still have a lot to learn as a student, and criticizing a PA experienced with sleep medicine and internal medicine will only set you up to fail. I am not advocating not putting this patient on CPAP, and never have. But once you get a bit of experience under your belt , you will find out that CPAP is not a cure. These folks have had years of insomnia that has revamped the GABA receptor sites in their brain through downregulation in addition to the airway problem that CPAP only partially corrects. I am not telling anyone to anesthetize their patient, only from my experience it is safe to use Lunesta to provide these patients with a better night's sleep. I have also seen it over and over, and good sleep hygiene will not do much to help an OSA patient. It will work wonders with your average insomniac. Now go finish your first year of PA school, complete your rotations in second year, finish 4 years more in sleep med, and then come back and we will talk again my young paduwan.

[Guest hubbardtim48]

I am trying to learn from expereinced PAs and not trying to criticize you. I have studied GABA receptors in undergrad in my molecular bio classes (a lot more than I am in PA school) and Lunesta is "THOUGHT" to work via GABAA receptor. Is there evidence that downregulation is occuring in OSA patients, because I have not found that yet. I have years of experience with OSA patients, just can't prescribe medications and I have seen tons of cases myself were OSA patients have a "cure" from a cpap/bipap without sleep aids. Again, I am not trying to be the big bad PA student, just really love pulm./sleep/cardio and have years of experience in patients with OSA and want to learn more. If you don't mind send me those research articles on the GABA receptor downregulation. Lastly, there is no need to "flex" your experience because your just being a d**k by stating and calling me a young paduwan. I think my statements were very true and not misleading and some opinion based, but over all I have seen hundreds of patients not needing sleep aids and that is why I was stating my observation.

[Guest hubbardtim48]

You should read the article in AARC Times from August 2012 Vol. 36, Issue 8. It talks about standards of care fro sleep apnea patients. Long-term compliance after five years of use is estimated to be 68% so education, education, education is the key for the treatment of OSA. Routine visits for effective treatment = 6-12 monts and sub-optimal compliance or sub-therapeutic benefit should f/u 2-3 months to eliminate problems such as break-through snoring or continue daytime fatigue. More alternative therapies includeoral appliances, behavioral modification and/or surgical procedures such as uvulopalatopharyngoplasty or mandibular advancement. Also, obesity is a major risk factor and dietary weight loss should be combined with proven treatment of OSA according to the American Academy of Sleep Medicine.

[MrBob]

Having sleep apnea myself (getting old ain't for sissies) an occasional sleep aid is a blessing. Just because you have provided someone with a C-pap or bipap, you still have a mask on (or nasal pillows) and a tube to deal with along with the noise and the air blowing in your nose. I have had a C-pap for about 5 years and can tell you that you never really become accustomed to it. Also my personal experiences with sleep apnea are very interesting. The nights I ignore the C-pap I have night mares (really) and get elbowed as well by my wife...the nights I wear it, I have pleasant dreams (really) and no elbows. Also if you use an aid for ED, such as viagra or cialis, you get a very stuffy nose as a side effect (it is a vasodilator after all) and it is difficult to breathe through the stuffy nose with the nasal pillow ( I do not use a full mast). So, bottom line, all science aside, I prescribe sleep aids for patients who ask for it for occasional use. It is safe and effective if used correctly. At least that has been my experience and I have a bunch of sleep apnea patients.

 

This is probably one of the most common/least diagnosed problems in adults.

[rcdavis]

Holy $hit, it lives!

Hollingsworth, you are alive!

[EMEDPA]

Holy $hit, it lives!

Hollingsworth, you are alive!

That was my thought as well.

[MrBob]

That was my thought as well.

 

(LOL)...yep It has been a very, very busy couple of years. I sold my medical practice to the local medical center (very happy with the outcomes from that), have been teaching for University of Phoenix, Walden University and St. Francis's masters program online, am a town councilman for our tiny community now. BTW I still practice but now in the MC's facility. Owning your own practice is a lesson in business and patience. It is a lesson in how to be frugal and how to market.

 

Anyway. I am glad to be back and will be here way more often than I have in the past, well, however long I've been gone. :smile:

 

I am on the Professional Practice Commission of the AAPA now (have been for a couple of years).

 

I am surprised you all remember me (LOL)

 

Let me share something interesting. Be careful what you write here....I was a professional witness for a malpractice suit recently and the opposing attorney accused me of believing that PA's didn't need to be supervised. I asked her where in the world she got that crazy idea. Her answer? From this forum....she had downloaded everything I ever wrote here and used it to try to establish or discredit me.

 

Lets get back to the sleep apnea thread.......thanks for welcoming me back. At least I think that's what you were doing.....

[True Anomaly]

Welcome back Bob! Glad that selling the clinic was a positive experience.

 

To your last point, I'm surprised more folks here aren't aware of observing what they type, especially when their name is clearly visible. Not that you've said anything untoward in the past, and I'm sorry you've had it thrown at you by attorneys, but moreso students or pre-PA's. Pretend like your boss/program director/admissions committee is reading your words before you post them.

 

For those who don't know already, the PA world is a VERY small world. While 80,000 may sound like a lot of people, if you poke around just a little bit, you'll find that we're all connected, and everyone knows someone who knows someone else in this field

[Guest hubbardtim48]

Thanks MrBob for the information. I am at a learning stage (and will always be learning), but as a PA student I try to reflect back on my RT experiences and try to apply them to what I am learning now. My goal was try to treat the sleep apnea by other means than meds...I understand there are many different routes one can take and I would think as a future PA try to practice as holistic as possible because that is my belief in life and would try to use it in my daily practice. There is a good article in the PA Professional Magazine on Sleep Disorders in the August 2012 edition on page 28-29. Thanks again for your reply! :)

[MrBob]

Well, Holistic is fine, but the real world is the real world. When you get out here and begin practicing, much of what you learn in school is very appropriate yet becomes a guide to real experience. Good luck. Remember this...no matter what the "old guys" tell you...they were once you. None of us were born doing this. We all made mistakes and learned through exposure. So will you.

 

Bob