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a blog about sleep apnea and other sleep conditions

Michael Morgenstern, MD
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Michael Morgenstern, MD

About the author: Dr. Michael Morgenstern is double board certified in Neurology and Sleep Medicine and the founder of the American Sleep Apnea Society. He is the Director of the Morgenstern Medical in Lake Success, NY, where he treats patients with sleep disorders and other neurological conditions.
Michael Morgenstern, MD
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Screening Railway Workers for Sleep Apnea (part 1)

On December 1st, 2013, a Metro North passenger train derailed in the Bronx, NY, killing 4, injuring 61 and causing $9 million in property damage. Unfortunately, this accident was not a lone event. According to the Federal Railroad Administration (FRA) Office of Safety Analysis there were 11,233 train incidents including 1,856 accidents and 1,314 derailments in 2015, resulting in 821 lives lost. Among commuter trains, 1,453 passengers were injured and 17 were killed. While the lives lost are the greatest tragedy, the financial costs of these disasters are also massive. Statistics indicate that over the next two decades a subset of trains carrying ethanol or crude oil will derail 10 times per year, resulting in at least $4 billion in damages according to estimates by the Department of Transportation. This figure could be significantly greater if a single railway disaster takes place in a densely populated area like New York City, where damages from such a disaster could reach $11.8 billion.

In October of 2014, the National Transportation Safety Board (NTSB) concluded that the Metro North derailment was caused by the driver of the train falling asleep due to undiagnosed obstructive sleep apnea (OSA). A five-year study of main-track train collisions by the FRA found that 30% of collisions are related to fatigue.

The Federal Railway Administration (FRA), in conjunction with the Federal Motor Carrier Safety Administration (FMCSA), published a request for comment in the Federal Register in docket numbers MCSA-2015-0419 and FRA-2015-0111 to gather information related to the evaluation of safety sensitive personnel for moderate to severe OSA. In response to this request, the American Sleep Apnea Society has prepared this white paper (which will be posted here in various parts over the next coming days) to address specific questions provided by the agencies.

Given the high prevalence of OSA in railway drivers, the need for screening is urgent. Data suggests that 35% to 62% of railways workers have sleep apnea—a rate that is two to four times greater than the general population. As in the general population, the prevalence increases with risk factors such as age and obesity. A significant amount of these disasters could be prevented by proper screenings that identifies drivers who are likely to be impaired by fatigue.

A comprehensive approach should include testing for the presence of sleep apnea, evaluation for signs of functional impairment, and worker education to prevent and counteract sleepiness during work. . Railway workers provide an invaluable service. The lives of others are often dependent on their ability to drive a train while fully functional, at any time, whether at 4 PM or at 4 AM. Since research has demonstrated that self-reported symptoms of sleep apnea in transportation workers are often unreliable, all railway workers in safety sensitive positions should be routinely tested for sleep apnea and impaired function using objective measures.

Those certified to drive a train should:

  • Have no sign of sleep apnea on Home Sleep Testing (HST), Polysomnography (PSG), or provide evidence of successful sleep apnea treatment.
  • Pass a driving simulator test that mimics nighttime conditions and/or a maintenance of wakefulness test, demonstrating that they do not have a high likelihood of falling asleep when they need to be alert.

Additionally, railway workers should be educated about the risk of driving while sleepy, instructed on proper sleep hygiene, and encouraged to utilize caffeine, rest stops and naps to counteract sleepiness when they are working. A comprehensive screening program in railway drivers should also incorporate safety data collection, so that the benefits of restrictions could be evaluated over time and improved upon. Sleep apnea screening programs can be used to complement other promising technologies such as positive train control (PTC) systems to improve overall railway safety.

Implementation of these recommendations will reduce fatigue related collisions, benefit the health and longevity of railway workers, and reduce their healthcare costs over time. In general, patients with untreated OSA are more likely to have worsening or development of obesity, depression, hypertension, diabetes, stroke, coronary artery disease and cardiac arrhythmias. Their average annual health care costs compared to those without sleep apnea are greater by $1950 to $3899. Therefore, screening of railway workers can efficiently reduce collisions, improve health and result in cost savings.

 

Trying Out CPAP for the First Time

trying out cpapI am excited to be trying out CPAP (continuous positive airway pressure) for the first time tonight. I am looking forward to getting a few things out of it. Since I treat patients with sleep apnea regularly, I plan to gain insight into providing better care for my patients. On a more personal level, I hope to gain some benefits from trying out CPAP, such as losing some weight, as CPAP usage is associated with weight loss. I also have an office pool going on who can lose the most weight in a month, so this, in addition to diet and exercise, might help me win. The other benefits such as improving my health, having more energy during the daytime and snoring less (if I actually do ever snore–I have never heard myself snore) will also be welcome. As I gain insight, I hope to share my experience of trying out CPAP with readers in a series of blogs and videos.

Why I am trying out CPAP

I  have been convinced that trying out CPAP might be the best thing that I can do for my health and wellbeing at this stage of my life. Most of my patients who have sleep apnea are treated with CPAP. They have often provided me with very positive feedback of their experience. Some have compared the technology to being the best invention since sliced bread. Others have told me their sleep is better, that they have more energy, are no longer tired, or that their high blood pressure has come down without medication.

CPAP is the best sleep apnea treatment

CPAP is the best treatment for sleep apnea. That is good considering I may have some mild sleep apnea. Apnea is broken down into mild, moderate or severe based on how many apneas take place, on average, in an hour. Less than 5 events/hour is considered normal, 5 – 14 events/hour is considered mild (that’s where I may fall), 15-29 events/hour is moderate and 30 events/hour or more is severe. In cases of more mild sleep apnea, symptomatic improvement is the goal. In other words, the goal is to feel better or reduce other physiological effects of sleep apnea, like elevated blood pressure. I often suggest to patients who have mild sleep apnea that they try out CPAP for at least three months. If they notice benefits they can continue. If they have problems tolerating the device, then alternative therapies are available or consideration can be made for stopping therapy if they receive no benefit from treatment.

I am starting out with the Resmed S10 and the Wisp Nasal Mask. In the future, I plan to create videos describing different machines and masks, perhaps reviewing them for others who are considering using them. I will post them to Youtube on the newly created YouTube channel of the American Sleep Apnea Society.

Michael Morgenstern, MD
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Michael Morgenstern, MD

About the author: Dr. Michael Morgenstern is double board certified in Neurology and Sleep Medicine and the founder of the American Sleep Apnea Society. He is the Director of the Morgenstern Medical in Lake Success, NY, where he treats patients with sleep disorders and other neurological conditions.
Michael Morgenstern, MD
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Sleep Apnea Could Have Caused Scalia’s Death

scaliaOn February 13th 2016, Antonin Scalia, one of the most famous Supreme Court Justices in the history of the United States passed away in his sleep. He died suddenly. The presumed cause of death was a heart attack. This came as a shock as Justice Scalia seemed to be relatively healthy, living an active lifestyle when not on the bench. He was a highly functioning individual up until the time when he went to bed on the night of the 12th. Heart attacks are less likely during the night than daytime at at time, when activity increases stressing the heart. Therefore, when cardiovascular events like heart attacks or strokes take place at night we should question the underlying cause. Some conspiracy theorists have suggested foul play. I doubt that. I believe a medical explanation might be more reasonable to explain what might have predisposed Justice Scalia to having a heart attack during sleep.

Heart attacks most likely the morning

In the general population the peak occurrence of cardiovascular events takes place between the hours of 6 AM and 11 AM, shortly after waking. Normally, waking causes a natural surge in cortisol and sympathetic activity to get you going. Consequently, blood pressure and heart rate rise and this increases the risk of cardiovascular events. Heart rate and blood pressure increase further during activity. In contrast, blood pressure and heart rate normally decrease during sleep giving your heart a rest along with the rest of your body.

What could have caused Scalia’s heart attack?

The exception exists in patients with uncontrolled sleep apnea who are predisposed to having heart attacks at night. As these individuals struggle to breath against a closed airway, their blood pressure and heart rate spikes upwards. This leads to a peak of heart attacks and strokes between the sleeping hours of 12 AM and 6 AM.

When I heard of Antonin Scalia dying in his sleep one of the first things that came to mind was the relationship between sudden death at night and sleep apnea. Justice Scalia was also reported to be overweight and have hypertension, two other risk factors for sleep apnea. While the general population enjoy sleep as a refreshing experience for their mind and body, and their blood pressure and heart rate also decrease, those with untreated sleep apnea may experience the opposite. They see a spike in their heart rate and blood pressure increasing the risk of dying from a heart attack or stroke in their sleep.

References

Gami AS et al. Day-Night pattern of sudden death in obstructive sleep apnea, NEJM 2005; 352:1206-14.
Kohli P, Balachandran JS, Malhotra A. Obstructive sleep apnea and the risk for cardiovascular disease.

The Most Viewed Sleep Science Writer on Quora

I have been spending a lot of time answering sleep related questions on Quora. As you will note in the image below, Michael Morgenstern is listed as the most viewed writer in Sleep Science with more than three times as many viewers as the next closest author at the time of this writing. You can also follow me there, though you might have to join the website, which is free.

I was considering adding a Q&A message board on this site, but why reinvent the wheel? Quora has done a pretty good job at connecting questioners with others, even experts, who are willing to provide answers. Answers can be upvoted or downvoted. There is a good amount of data already on the site related to sleep.

Quora

The way that Quora works is you can ask any question and then ask people to answer. If you have any specific questions about sleep or neurology, you can go to Quora, ask a question and request that I answer it for you. If I’m not suggested as an author, you can search for “Michael Morgestern” and then  my profile should pop up.

I will try and see if I can integrate the answers onto the American Sleep Apnea Society website. In the meanwhile, if you are interested in asking any questions feel free to do so through Quora.

Michael Morgenstern, MD
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Michael Morgenstern, MD

About the author: Dr. Michael Morgenstern is double board certified in Neurology and Sleep Medicine and the founder of the American Sleep Apnea Society. He is the Director of the Morgenstern Medical in Lake Success, NY, where he treats patients with sleep disorders and other neurological conditions.
Michael Morgenstern, MD
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Donald Trump Dress Shirt Predicts Chance of Sleep Apnea

donald trumpWe have learned a lot about Donald Trump recently. We have learned about his political ideas. We have heard Mr. Trump’s proposal about building a wall. Whether your a fan of Donald Trump, or not, I think there is something very important we can learn from him. It has nothing to do with politics. It has to do with health. It does have something to do with walls–a different kind of wall–the wall of your upper airway. In fact, Donald Trump dress shirts can be used to predict the chances that you or your spouse may have sleep apnea.

Donald Trump Shirts

If you have ever been to Macy’s, although, perhaps not lately1, you may have noticed that Donald Trump has his own line of Trump branded dress shirts. If you wear one of these dress shirts then checking your collar size can reveal something very important about your health. Research shows that your collar size can indicate if you are at risk for sleep apnea. Larger necks are associated with a narrower upper airway and more collapsible pharyngeal wall.

Donald Trump & Neck Size

Male adults with a neck size of greater than 17 inches, and females with a neck size of 16 inches or more, are at increased risk for sleep apnea. Most people wear a collar size that is half-an-inch larger than their neck circumference. If you wear a size 17.5 your neck is probably about 17 inches. As neck size increases, or Donald Trump dress shirt size increases so does your risk of sleep apnea. If you wear a size 19.5 collar, your chances of having sleep apnea are about 20 times higher than the general population. A study examining larger neck sizes found that 90% of individuals with neck sizes larger than 16 inches in circumference had sleep apnea. A neck size smaller than 16 inches does not mean that you don’t have sleep apnea, especially if you have other symptoms.

When you see Trump take a second

collarThe truth is you don’t need a Donald Trump dress shirt to learn this important fact about your health. Any dress shirt will do. For that matter, any measuring tape will work as well. However, if you will accept this association, the next time you see Donald Trump on TV on the News or hear about him on the radio or wherever, take a second. Appreciate how he is always wearing one of his branded dress shirts and ties. Then think about your sleep and about your collar size. If you are male and it’s larger than 17 inches or if you’re female and it’s greater than 16 inches, talk to your doctor about getting screened for sleep apnea. It may be the most important thing you can learn about from Donald Trump. It could also save your life.

Note

1. Macy’s announced they were ending their partnership with Donald Trump in July 2015.

Michael Morgenstern, MD
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Michael Morgenstern, MD

About the author: Dr. Michael Morgenstern is double board certified in Neurology and Sleep Medicine and the founder of the American Sleep Apnea Society. He is the Director of the Morgenstern Medical in Lake Success, NY, where he treats patients with sleep disorders and other neurological conditions.
Michael Morgenstern, MD
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Intro to Sleep Apnea

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Sleep apnea blog

This sleep apnea blog was started to provide updated, accurate medical information about sleep apnea. Too many websites online have incorrect or outdated information about sleep apnea. So this sleep apnea blog was made to help counter some of the other information out there and provide a resource for other websites. Have you enjoyed our sleep apnea blog? Let us know.