“Xi – Kah – Vah”
“Xi – Kah – Vah” ….
I stored repeating this mentally hoping my outdated Transcendental
Meditation mantra would ship me off to sleep. That was after I had repeated the
US Military leisure approach that was assured to convey on sleep. It was 3AM and I used to be nonetheless wakeful. Nonetheless worse – I used to be in a sleep lab making an attempt to
discover out why my AHI has been pegged for the previous 3 months. AHI is the Apnea-Hypopnea Index and in accordance
to the producer of my CPAP machine is measure the variety of apneic episodes
per hour that last more than 10 seconds.
For the 20 years I’ve been on CPAP – the quantity has been 1-3, however 3
months in the past it began going as much as 10+ with no good rationalization – apart from
attainable central sleep apnea along with obstructive sleep apnea.
My physique weight and normal life model has not modified at
all. I proceed to get good general
scores on my CPAP machine regardless of the AHI.
I consulted my sleep drugs doc and he determined to extend the
strain and see if that labored. It did
not – so we determined to do one other sleep lab take a look at or polysomnography. It’s a
large deal since you’re noticed and filmed, related to electrodes (EEG, ECG,
OCG, laryngeal vibration, chest and belly respirations, legs (for RLS), and
masseters for bruxism.
An unsettling issue within the combine is that in line with
polygenic threat evaluation – I’m loaded for Amyotrophic Lateral Sclerosis (ALS)
genes. And by loaded, I imply I’m within the
100th percentile for threat. I
am not conscious of central sleep apnea being the preliminary signal of ALS and neither
was my sleep drugs doc – however I don’t wish to be the primary case report. So, I hope these genes stay quiescent
and don’t specific themselves.
I confirmed up on the lab at 8PM. A technician defined their protocol and
that after I used to be related, I wanted to contact her through the intercom if I
wanted to stand up at evening. Underneath no
circumstances was I presupposed to stand up on my own as a result of it will endanger all
the electrode connections. I instructed her I
was prepared and he or she got here again in and hooked me up over a interval of about 20
minutes after which examined the connections. She additionally defined that I used to be not
going to be began on CPAP – it will be added later within the evening provided that I
wanted it after which BiPAP could be added on prime of that if I wanted it. Since I already had a analysis of
obstructive sleep apnea (OSA) – that didn’t make lots of sense to me. However I used to be not upset and wished to proceed
with the ordered protocol. I watched TV
for about 20 minutes and it was lights out by 10PM.
It didn’t take lengthy to appreciate that I used to be simply laying there
pondering. I recalled my first
polysomnography in a sleep lab that was constructed within the Neurology Clinic of the
hospital the place I labored. I had the
feeling at the moment that I didn’t sleep a wink however the tech mentioned – “Oh no you
slept all proper and you’ve got extreme sleep apnea.” (AHI>50). Since that point, I’ve been 100% compliant
with CPAP. I take advantage of it each evening – no
matter the place I’m.
I checked my watch and it was 1AM. Three hours of laying there pondering and no
sleep in sight. Time to attempt my sleep
reverie trick. Sleep reverie is a
dependable signal of sleep onset being very shut and, in my case, it takes the
type of vivid and sometimes nonsensical psychological photographs. For instance – the picture of a person strolling down
steel stairs from a loading dock. A person
engaged on an outboard motor. A
futuristic grey pickup truck driving down the street. A 500 ml beaker in entrance of a small flat
display screen TV. These photographs flash for a number of
seconds and I’m asleep. A while in the past,
I believed I may pace sleep onset by recalling the early states of sleep
reverie. What did it really feel like within the
physique and mind simply earlier than the photographs began? I attempted reproducing these sensations a number of
occasions and virtually had it. I generated a
transient flash of sleep reveries and it was gone – I used to be nonetheless wakeful.
I checked my watch and it was 3AM. Nonetheless wakeful. Flash on my mantra, muscle leisure, respiratory
workout routines, mindfulness workout routines – all of the tips of the commerce and I bought
nothing. My thoughts is wandering to distant locations. I’m again in Africa in 1974 touring up into
the Aberdare Mountains to go to mates.
I’m 25 years outdated and touring with a younger girl who’s 23. We’re travelling in a high-speed taxi referred to as
a matatu. They arrive in varied
types however this one is a small Toyota choose up truck with a steel enclosure over
the again. My travelling companion and I
are crammed into that enclosure with a dozen villagers making an attempt to stand up into
the mountains. Each time I get out of
certainly one of this stuff – I kiss the bottom.
Many individuals have been killed in matatus yearly. I bear in mind how cool that
younger girl was. I flash forward to mountain climbing
within the bamboo forest along with her future husband and a mutual good friend. I flash forward to getting overrun by soldier
ants at his home up within the mountains and questioning if we have been going to outlive
that evening. In the long run we have been saved by
a paraffin fridge – ants don’t
cross a line of kerosene.
I checked my watch once more and it was 5AM. The technician’s voice came to visit the
intercom:
“You aren’t sleeping.”
“I do know – I got here shut a number of occasions – however by no means fell asleep.”
(referring to the aborted sleep reveries).
“Do you wish to simply stand up and depart?”
“I suppose”.
The technician got here in and took about 10 minutes to
disconnect all of the electrodes. I had 6
piles of salt and electrode paste on my scalp.
“It ought to come off with simply shampoo. Your physician will look
on the research. He could resolve to have you ever
come again and offer you a sleeping capsule.”
I considered what occurred on the way in which residence calling on my
years of learning sleep. I’ve had insomnia since I used to be a little
child with evening terrors – however I solely stayed awake all evening lengthy when it was
needed for my function as a doctor. The primary time was protecting the coronary
care unit as an intern and believing that one other intern and I have been accountable
for an individual on a balloon pump who was actively bleeding. Whilst a
psychiatrist there have been the occasional all-nighters – sometimes catatonic
sufferers who had questionable consumption or agitation and aggression that didn’t
reply to the standard measures. And of
course, sophisticated medical issues that at all times appeared to finish up on my
unit. It bought worse with the digital
well being file as a result of I may see virtually all the pieces from residence. However none of that could be a downside in
retirement. My sleep is usually regular
and I’ve no downside getting at the very least 6-7 hours per evening.
The behavioral facet of sleep supplies some clues. All of us study to go to sleep in a sure
atmosphere. The atmosphere I’m used
to is connected to a CPAP machine. It
has a sure sensation and noises. The
air splint from the strain creates a sure inside sensation. Regardless that
I used to be not bothered by making an attempt to sleep with out it – the dearth of these sensations
could have been the explanation I couldn’t sleep in any respect.
A second difficulty was the mattress.
I used to be handed a distant management and suggested I may regulate the firmness of
the mattress with the distant. I did it
at each time verify dropping it by 30 p.c every time. By 5AM I used to be all the way down to 30 (the place 100 is the firmest). I lately modified my residence mattress and it
required a trial earlier than I may discover an actual substitute. There’s a literature on mattress qualities
and sleep that appears at firmness, temperature, and supplies. Many of the research are considering sleep
however some have a look at spinal alignment and ache.
The outcomes are typically blended most likely on account of affected person
traits. For instance, though one
overview (1) finds {that a} medium agency mattress may match for most individuals –
there are nonetheless are these at each ends of the spectrum that sleep higher with
very agency or tender mattresses. I
bought my final mattress primarily based on a research that I believe was within the British
Journal of Drugs (BMJ) suggesting that pillow prime mattresses may match
the perfect. With the substitute I attempted a agency orthopedic mattress that resulted
in again ache daily. A brand new pillow prime
labored very nicely. The sleep lab mattress did
not appear to vary in any respect with the distant management and that will even have been a
issue.
So how do you fail a sleep research? The brief reply is by not sleeping however there
are complicating elements. I’m ready
to search out out if there can be a modified protocol and watching my AHI.
George Dawson, MD, DFAPA
1: Caggiari G, Talesa
GR, Toro G, Jannelli E, Monteleone G, Puddu L. What sort of mattress must be
chosen to keep away from again ache and enhance sleep high quality? Evaluation of the literature.
J Orthop Traumatol. 2021 Dec 8;22(1):51. doi: 10.1186/s10195-021-00616-5. PMID:
34878594; PMCID: PMC8655046.