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Cheryl: This is Heart Speak, the podcast from Baylor Scott & White Heart and Vascular Hospital in Dallas and Fort Worth. I'm Cheryl Martin. Today, we welcome Dr. Eneida Harrison to the show, a board-certified pulmonologist who specializes in critical care medicine and sleep medicine. She's the medical director at the Baylor Scott and White Heart and Vascular Hospital Sleep Center.

Dr. Harrison will address primary care providers in general about sleep disorders and the management of the patient with a suspected sleep disorder. In this segment, she will also review the correlation sleep disorders have with heart health. But before we get into some of the specifics related to identification, treatment, and management of sleep disorders, tell us, Dr. Harrison, why is it important to identify sleep disorders early?

Eneida Harrison, MD: I think sleep is interestingly a new field in medicine that before these last five, 10 years didn't get a lot of recognition. But the more that we're learning about sleep, the more we're realizing that it impacts so many different facets of overall health including cardiovascular health. It impacts people's overall psychological wellbeing. It impacts their metabolic health as well as disease such as diabetes. So, I think because it touches and has such a important bidirectional relationship with many of these health conditions, it becomes very important to recognize and to ensure that the patients are in fact having good, healthy sleep.

Cheryl: As primary care providers continue to wrestle with managing time and relationships with your patients, it could be challenging for a primary care physician to identify sleep disorders in some patients, unless of course a patient is forthcoming and mentions key triggers or symptoms. So, how would you recommend a primary care physician approach patients or coach their medical assistant or office team to assist in identifying a patient with a potential sleep disorder?

Eneida Harrison, MD: Two aspects that I think would be helpful in answering this question would be to pay, first of all, key attention to people's overall BMI. And that anyone that has an elevated BMI, to consider asking specific questions. For example, assessing fatigue, if there's tiredness, excessive daytime sleepiness, if patient or their partners endorse them having loud snoring, having gasping for air at night, or things like waking up with an early morning headache or dry mouth. That being said, it's important to realize that there are gender differences. For instance, women are less likely than men to endorse having some of the most classical sleep apnea symptoms such as snoring or apnea. And they're more likely to endorse having symptoms, for example, such as insomnia, depression, mood disturbance, or just a little bit of fatigue.

And so, it's important to also keep the index of suspicion high for females in general as well as other ethnicities like Southeast Asians or Asians in general, where the BMI does not have to be high, they don't have to be obese or morbidly obese because of their overall anatomical variance, they're more likely to have sleep apnea. So, just even the simple question, "Tell me about your sleep," can open up a good dialogue or conversation to address this further.

Cheryl: You did mention some symptoms for women and also those in other ethnic groups. Are there other different symptoms presenting in women and men as well as other ethnicities?

Eneida Harrison, MD: It's not that the symptoms are different. I think one key symptom that, you know, might be similar among, for example, men, females, and people of other ethnicities would include sometimes having fatigue, kind of interrupted sleep during the course of the night, so sleep fragmentation.

Things that, for example, might be more common in guys would be things like loud snoring or apneas. This might not be a symptom that females endorse. Some people think that, you know, females might perceive this as unladylike or might not be, you know, really thinking that they themselves have it.

As far as other ethnicities, they would pretty much still follow the same symptom pattern. It's just that their overall body habitus doesn't have to be really high in order for the physicians to really start thinking or entertaining the diagnosis of obstructive sleep apnea. So, the symptoms would be the same. It's just that the patient's physique is not the typical physique that we tend to think of when we think of obstructive sleep apnea.

Cheryl: Now, primary care providers may have patients who were diagnosed with a sleep disorder years ago and essentially just gave up on their nighttime CPAP machine. What's changed in the way of these devices, the CPAP and other available treatment options.

Eneida Harrison, MD: One exciting treatment modality that's hit the market in the last few years is Inspire or hypoglossal nerve stimulation. Essentially, it can be described as a pacemaker-like device that provides neurostimulation to the branches of the hypoglossal nerve which is activated when breathing starts. And this activation leads to tongue protrusion, which in turn opens up the pharyngeal airway and prevents obstruction. So, for patients who have moderate to severe sleep apnea who are intolerant or just couldn't make CPAP work, this is an exciting new modality that can be considered.

One aspect that at times can, you know, be prohibitive is BMI. So, the best candidates are those with the BMI of 32. That being said, sometimes when I see patients in my clinic who might be above that BMI threshold, like I don't discourage them, sometimes this might even be the stimulus they need to lose those extra pounds just knowing that this might open the doors for other therapeutic interventions. So, from a primary care perspective, if you have a patient who has been unable to tolerate CPAP, I would consider this as a potential patient to refer for Inspire therapy evaluation.

Cheryl: Any other treatment options for these patients?

Eneida Harrison, MD: Sometimes if they're not inspired, they don't want to pursue Inspire, there are other surgical treatments done by ENT. One of them is UPPP, which is a process of widening the airway by removing part of the soft palette, uvula and tonsils. Sometimes a procedure done by dentists is actually a placement of oral mandibular devices, which are able to reshift the upper and lower jaws with the purpose of enlarging the airways.

So, even though by and large, CPAP is used a lot for the treatment of sleep apnea, it's not the only one. And for certain patients with sleep apnea who have a positional component, meaning that when they sleep supine, they have sleep apnea. But when they're sleeping in any other positions, they don't. Sometimes positional sleep devices can also be utilized to treat them of their disease burden.

Cheryl: So, let's say that a primary care physician or advanced practice provider has identified the probability for sleep disorder in one of their patients, what are the next steps?

Eneida Harrison, MD: So, once the primary care doctor has determined that the patient has features concerning for sleep apnea, the next step would be to determine whether to order an in-lab or a home sleep study. For most patients, especially relatively healthy adults, doing a home sleep study, especially if they have a moderate severe chance of having sleep apnea, would be sufficient. Conditions that create more of an incentive to order an in-lab would be things like, you know, moderate to severe lung disease, a patient being on home oxygen; patient having heart failure, class III or IV heart failure; if patients have neurological conditions like seizure or stroke, which can increase their likelihood of having kind of more complex apneas like central sleep apnea; and patients who have really high BMI, very morbidly obese, those would be factors that would sway want to go more for in-lab instead of home sleep studies.

Cheryl: And so when you say lab, you're talking about an overnight study?

Eneida Harrison, MD: That is correct. Like an attended polysomnogram.

Cheryl: Now, what should a primary care provider and office team consider when making a referral to a sleep center? And what training is important for the specialists they will be referring patients to for further care?

Eneida Harrison, MD: So, the biggest factor in my opinion is the primary care's comfort at handling both the diagnostic or the therapeutic aspect of a patient with sleep apnea. So if a primary care doctor, for example, has ordered the diagnostic test and they find out that the patient has sleep apnea, then that sometimes would be a place that would open up a referral to a sleep doctor. There are sometimes certain insurances that may necessitate the patient to be seen by a sleep professional before the patient gets, for example, one of these therapeutic interventions that we talked about. Sometimes once the patient gets started on these and they're stable, we may refer them back to the primary care doctor if they feel comfortable managing it. But if they don't, we're happy to continue seeing the patient and managing their disease. And if the primary care doctor does not want to, I guess, worry about sorting through which test to order for that patient, but they feel that they have some sort of sleep disorder, they can also elect to refer the patient at that particular point.

So, there is no right and wrong answer. The biggest thing is to just ensure that each patient is getting the diagnostic study and getting started on therapy as soon as possible. So, as a sleep physician, that's like the most important part for me. And so if I can assist at any point, whether in the diagnostic or therapeutic, that's a perfectly acceptable place to start.

Cheryl: Anything else you'd like to add regarding managing patients with sleep disorders?

Eneida Harrison, MD: I think the last take-home message I wanted to mention, which I kind of alluded to the start of this interview, is just how important sleep is. We spend essentially a third of our life sleeping, and so it's not surprising that what happens during this one third of our life has such tremendous consequences and everything else that impacts that patient and I think that an important point that, you know, primary care doctors can use to their advantage in a lot of the discussions they have with the patients. Because it's not just about sleep, although that's also important, but it's also, for example, how sleep impacts other aspects of, you know, their cardiovascular health, their risk of developing hard to treat high blood pressure, stroke, heart disease, atrial fibrillation. So, it's very important to keep all of those aspects in mind when you're thinking about how you screen these patients, which tests you order and the treatment that come as a result of it.

Cheryl: Dr. Harrison, thanks so much for being with us. Some great information.

Eneida Harrison, MD: Thank you.

Cheryl: And thank you for checking out this episode of Heart Speak. Providers. If you are in need of assistance for a patient with a sleep disorder, please call 4 6 9 7 0 2 0 7 2 5 directly. That's 4 6 9 7 0 2 0 7 2 5 to speak with someone at the Sleep Center on the Dallas Campus who will be able to assist you and your patients.

The public can find a specialist at Baylor Scott and White Heart and Vascular Hospital in Dallas or Fort Worth. By calling 8 4 4 2 7 9 3 6 2 7. That's 8 4 4 2 7 9 3 6 2 7. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for more topics of interest to you.

Thanks so much, and we'll talk again next time.