Helping Them Sleep in the Lab

The patient is 65 years old and he stops breathing every 30 to 40 seconds throughout the night, a condition known as "sleep apnea". In a case as severe as this the victim awakes unrested and feels the irresistible need to sleep during the day.

Tonight researchers will carefully monitor and record every function of his body having to do with sleeping and breathing. He has been transferred from Harvard affiliated Massachusetts Eye and Ear Infirmary to the Sleep Disorders Clinic and Laboratory in nearby Harvard affiliated Massachusetts General Hospital.

At 11 p.m. two hours after the usual entry time the patient is admitted. He has electrodes and other devices strapped and taped to his head and upper body. But like most apnea patients, he is so tired that not even these prevent his almost immediate sleep.

Also almost immediately, the patient stops breathing. The readout of his vital signs, led by in formation from the devices on his body into 17 sapphire tipped pens sliding back and forth on a continuously moving strip of paper, instantly reflects the change.

The line showing airflow through mouth and both nostrils drops to nothing. The heartbeat reading becomes erratic. Movement of chin and chest are spasmodic as the patient struggles to draw in air. Eye movement changes and nine channels of brain wave recordings take on the appearance of waking brain activity in the thin blue lines.

Finally, after about 10 seconds the patient takes a breath. The functions return to their previous appearances. A television monitor, displaying the darkened bedroom for those outside watching the readout, reveals that the man is once again breathing fairly normally.

Then 30 seconds later, it happens again About 100 times an hour from 11 p.m. until 6 or 6.30 a.m. the patient will temporarily stop breathing. Chances are he will hardly remember it, but each time he wakes up briefly. He will remain fatigued all day.

In the next room, also hooked up to a variety of monitors and a recording device, is a 30-year old woman who suspects that she has insomnia. She arrived at about 9 p.m. the usual hour for patients to enter the lab for overnight stays, and her vital signs will be recorded until 6 a.m. as well. She is an outpatient, in the clinic just for the night, and unlike the sleep apnea patient, she requires no supervision from the lab's two-man team.

The woman's readout is similar to the man's though several of the functions being monitored are different. Whenever she turns over or even moves more than slightly, the readout goes haywire as the connecting wires vibrate. The pens shoot back and forth so quickly that the resulting pattern is almost solid black. This patient can be left alone, for her diagnosis will be determined during the day by reviewing the information on the printout. The lab team will devote most of their attention to the man.

"He's trying to breathe, but he can't--it's as if someone is strangling him," explains Dr. John W. Stakes III, instructor in neurology and supervisor of the nightly tests. Other doctors handle the lab in the daylight hours, but on Monday and Tuesday nights, Stakes is in charge.

Aside from the severity of his case, Stakes adds, tonight's patient is typical of apnea sufferers. He is in late middle age, moderately obese, with a short neck, and male. Most apnea victims are, and their wives bring them in to this clinic or others like it complaining that while their spouse has always snored, recently they have noticed that he seems to stop breathing.

Stakes says that this patient has the worst case of apnea he has seen in "quite a while," and the lab technician. Margaret A. McMahon, agrees. McMahon monitors the sleeping patients, making sure that the readings are of the highest available quality.

This evening, the chest movement monitor has been strapped on the man incorrectly so that the graph is not as clear as it might be. Shortly after midnight, McMahon goes into the room followed by Stakes, to adjust the strap around the patient's chest. It needs to be moved further down his body because he appears to be breathing less with his chest than with his abdomen.

McMahon will spend the rest of the night making sure the patient is still wearing all of the mechanical devices he should be and recording his blood's oxygen saturation reading Displayed on a digital readout, the oxygen saturation measures how efficiently the body is inhaling and distributing oxygen. A normal saturation is around 95 to 97, but this patient's seldom exceeds 80, and drops as low as the low 40s during apnea episodes McMahon noting the reading every few seconds, will mark it in felt-tip pen as the paper rolls along.

Sleep apnea victims are "the most difficult patients to monitor." McMahon says, jotting numbers constantly. She seems unperturbed by the continual struggle going on in the darkened cubicle. The only sounds are the scratching of pens on paper and the occasional bushed voices of the doctor and the technician.

The lab has investigated a variety of sleep disorders since it opened in September, but has only been fully funded since April 1. It has managed to operate on a "relatively low budget," explains Stakes, because the lab shares facilities with an electroencephalogram (EEG)--brain wave--laboratory which operates during the day.

Stakes estimates that 15 percent of the population suffer from sleep disorders of one kind or another. Some of the patients in the lab have been children as young as six, but as a rule, sleep deprivation does not begin the age of 11, when the child starts staying up late, usually to watch television.

Right now, his lab can accommodate only two patients, two nights a week, but Stakes says he plans to have it operating at capacity--three patients, two nights a week--within two or three years.

"The lab extends our diagnostic capability from just routine EEG sampling to a seven to eight-hour period of monitoring the patients," Stakes says.

McMahon says her favorite type of patient to monitor is the victim of "sleep terror," the "most interesting and scariest" disorder she's seen since she began to train as a technician at Mass General 13 years ago. Such a patient will awaken from non REM (rapid eye movement) of non dream sleep, in terror for no apparent reason.

Other disorders the lab deals with include nocturnal epilepsy (seizures only at night); nocturnal myoclonus (jerking of the legs during sleep) and narcolepsy.

Natcolepsy continual and unpredictable falling asleep during the day is a syndrome diagnosis according to Stakes. That is it can have many different causes, all with the same manifestation. Reasons for it include sleep deprivation, apnea metabolic diseases such as hypothyroidism tumors, and difficulty recovering from strokes.

Narcoleptics go into REM sleep the stage of sleep during which dreams occur much sooner than normal patients, and more often during the night. There is also another form of the disorder known as cataplexy, in which the victim loses muscle tone and control of the body when experiencing strong emotions, such as excitement or anger. Stakes tells of one patient who, when he tried to punish his children by whipping them was unable to do so because when he tried to remove his belt he became "very limp and weak."

Cataplectics generally remain conscious during attacks, but narcoleptics fall immediately into REM sleep. In either case, "some of these people have been labelled crazy, and they're not," says Stakes.

"If you can diagnose accurately, you can treat appropriately," he continues, explaining the "multiple sleep latency" test. During the course of one weekend a month, a patient is given the opportunity to sleep five times in 10 hours, and the sleep latency--time between going to bed and falling asleep--is measured.

Narcoleptics sleep at least two of the times, Stakes says, "within a couple of minutes," and enter REM sleep almost immediately. Normal sleepers take 15 to 20 minutes to fall asleep, and patients with disorders that involve not going into REM at all sleep within five minutes.

How does Stakes "treat appropriately?" Some disorders, such as insomnia, can be treated in the office. Other patients responded to antidepressant drugs, and some to simple adjustments in the sleep schedule. Still others only need reassurance that their sleep patterns are, in fact, normal. "We get patients coming in thinking they're not getting enough sleep when their sleep architecture looks great." Stakes remarks, referring to the structure of the printouts.

And he tells of an acquaintance who sleeps from 4 a.m. to 11 a.m. otherwise leading a normal life and conducting a successful law practice. The person has been on this schedule since college, when be arranged his schedule so he had all afternoon classes, as he did during law school.

But in the most severe cases, surgery is necessary. Apnea patients who do not respond to medication may need a pharyngoplasty, or surgical widening of the throat, and if the episodes are severe and frequent enough, a tracheotomy is called for.

This is the case with tonight's patient After the all-night session, the results of the monitors will confirm the diagnosis of a severe obstruction in his throat, and the need for a tracheotomy. In other words, the patient will have a permanent incision made in his throat, which will enable him to sleep uninterrupted by bypassing the block. "Laxity of the soft tissues in the throat and palate," according to Stakes, makes the operation necessary.

Meanwhile, the man is less restless than the average patient But suddenly, at 2.03 a.m. he putts off his chin monitor and tugs on his nasal airflow indicators McMahon swings into action.

"It's only me and I'm putting these back on." she says quietly slipping into the dimly room and reattaching monitor to chin "And these have to go back into your nose," she murmurs repositioning the apparatus.

Stakes leaves minutes later satisfied that she has it under control. Often say McMahon the doctor will stay especially if there is a patient who might encounter some sort of difficulty during the night and grab sleep when he can Stakes serves as a neurologist as well as an internist in day light and on nights when the lab is in service he says "I fit sleep in someplace".

The study of sleep explains Stakes is an extension of my internal medicine and neurology interests--it blends the training together.

As for McMahon she says generally enjoys but I only do it two nights a week, but she says of the hours, "that's one of the problems with working in a lab like this you tend to develop a sleep disorder yourself."

When there are no patients in the lab McMahon spends her time "scoring," that is translating the scribbling on the one third to one-half mile of paper generated in a night's monitoring into readable numbers. Each 20-second unit is assigned a number corresponding to the depth of the sleep during the period, and then marked on a grid. Those numbers can be led into a computer to aid the diagnosis of the disorder. The strips of paper are used so that both sides are written on, and they are microfilmed and thrown away. The microfilm is kept, however, because there may be recurrences of disorders.

Disorders sometimes overlap into other fields Sleep disturbance and over rapid REM sleep on set characterize depression, and manic depressives in a manic state can go many nights with only one or two hours of sleep, according to Stakes.

Relationships like these move into the area beyond disorders and into the actual meaning of sleep. Why, for instance, do viral infections like mononucleosis or even the common cold cause sleepiness?

Stakes does not have an answer, and there may not be one for a while, at Mass General or else where. The underlying problem, he says, is "not understanding the basis of the alteration of consciousness."

'That's one of the problems with working in a lab like this-you tend to develop a sleep disorder yourself.' Margaret A. McMahon