CAN ONE SLEEP ON IT ?

      I have not done much on sleep medicine stories. I do practice sleep medicine - mainly sleep   apnea. Bot some times we get different problems associated with sleep. To sleep on -is used when one wants to postpone making decision. But I m using it differently. We se patients that has certain characteristics of someone who has sleep apneas . Apneas means one stops breathing and Hypopnea means the breath is smaller and is associated with oxygen saturation drop. On an average we have these episodes less than 5 per hour. When they occur more than 30 per hour of sleep it is considered severe . And I have seen as high as 90 per hour. These episodes are counted as -episodes per HOUR OF SLEEP and not hour of recording. This brings me to story for today. 

   I have seen this patient for last few years. He was quite obese and had sleep apneas and that was treated with pressurized mask called CPAP-CONTIUOUS POSITIVE AIRWAY PRESSURE. This keeps airways open and the that prevents the apneas and hypopneas. He was doing good . Then he had some other medical problems - liver related and also has some personal problems that caused stress. He lost weight and was not sleeping well. he attributed that to old machine and  wanted new machine. I needed new sleep study to justify new machine as he had done the sleep study many years ago and he had new health insurance and they would not approve new machine without new sleep study. So we decided to do new sleep study. The sleep study was done  and he did not sleep well and the study came back showing he has NO SLEEP APNEA. He did not believe that and wanted second sleep study . the first was done in sleep lab and he felt that he could not sleep there in unusual surroundings. He felt that if we do the study AT HOME then he will be in his own bed and bedroom and he will sleep better.   The home sleep studies are not as good as one done in sleep lab , but his thinking was correct. People may not fall asleep in lab, as they are in unfamiliar surroundings. So I ordered Home sleep study . That also came back as having no sleep apneas. Now we both are stuck . He does not sleep well - in lab study he slept less than 10 % of the time. He definitely has Insomnia and when one does not sleep well during night , he will have drowsiness and fatigue and lack of energy during day time  and also will feel sleepy - all the signs and symptoms of sleep apneas. He wants me to get new machine and he wants me to increase the pressure settings on his current machine. No one will give him new machine unless he has diagnosis of sleep apneas and I cannot increase pressure when he does not have diagnosis of apneas . It is quite possible that he has NO APNES  and all the problems are related to Insomnia or it is also possible that he did ot sleep well when sleep study was done and so we did not get apneas. But there is not much we can do . I did order new sleep study with sleeping pill . But his insurance company REFUED THAT stating that he had already 2 sleep studies . 

  AND WE CANNOT SLEEP ON IT !!!

THE OLD DICTUM IS NOT ALWAYS CORRECT

     When we were in medical school , we were told that one does not  need of try to explain the symptoms with 2 different diagnosis . When a patient  is having some complaints , we should not have 2 different diagnosis to explain the problem . And that is true in many conditions and also in most patients .But sometimes we have 2 different diagnosis and then it becomes difficult to 'work up ' for 2 different diseases. This brings me to the story for today. 

    I had seen this male patient may be 3-4 years ago . He was admitted with pneumonia - 6 or more months ago and was seen by lung specialist .He was a smoker and had abnormal chest x- ray and then CT scan chest . He was treated with antibiotics and also  had bronchoscopy. He was discharged and was told that looks like he had cancer  and no diagnosis was done . He and his family were not happy and so they came to me. I reviewed the scans and the reports and realized that he had bronchoscopy and the samples - which take 6-7 weeks to finalized - was positive for atypical TB called MAC. I explained him the reports and started him of 3 different antibiotics  that needs to be continued for 18 months. I did tell them that he had abnormal CT scan and that needs to be followed as he could still have cancer. He was a smoker and had COPD. He did not have good lung capacity - reserve to do open lung biopsy.

    We followed him and did new CT scan several times and that continued to show improvement and the nodules that we were concerned had become smaller. We di complete the MAC medicines and then did CT scan and it continued to show improvement. Then last one was a problem . He had no new complaints and he had done sputum for TB - MAC and that was OK and the Ct scan showed that one of the nodules ,which was very small , like 4-5 mm or 1/5th of an inch , had doubled in size- still less than 10 mm or less than half an inch. I was concerned and I had interventional lung specialist do biopsy. This is relatively new procedure - may be 4-5 years old where computer guides to do biopsy in right segment and so the yield is high. This is more effective and when patient is not a good candidate for open lung biopsy due to poor lung capacity , we can get diagnosis. So the biopsy was done and HE HAD CANCER . So he did have MAC and he did respond to treatment - and he DID NOT have cancer 3-4 years ago - but now he has cancer .