My journey starts with a virtual visit* and exam with an ADVENT sleep & sinus expert.
*ADVENT no longer does virtual visits
Hi everyone, Erik here again continuing to document my journey with ADVENT to try and fix my sleep and breathing issues. I'm getting ready for my virtual consultation* with a sleep and sinus expert. This is going to be an ADVENT provider who's going to be asking me some questions, and then I'll be asking them some questions. We're going to see if ADVENT's going to be the right fit for me. Boy, would it be embarrassing if it wasn't [laughs]. Even though I've been working at ADVENT and have a pretty good grasp of the process and the options that are out there, I still have questions.
[Tiffany] Hi, Erik?
[Erik] Hello!
[Tiffany] I'm Tiffany, I'm one of the physician assistants. For these consults we basically just go over what we do at ADVENT to see if you would be a candidate for that and answer any questions about that. Any formal medical advice or ordering of prescriptions or ordering of any testing, we'd have to do an official new patient visit. Which we could also do today if you want.
[Erik] Okay, great
[Tiffany] So, what's been going on?
[Erik] So, about 6 years ago I was diagnosed with severe sleep apnea. I went through 2 in-lab sleep studies and I was told that I had severe sleep apnea. I was given a BiPAP and I've struggled to use it for years. The sleep clinic I was working with was very unhelpful. I was never given any options other than the CPAP. In addition to that, I really haven't been able to breathe well through my nose for my entire life. I broke my nose in 3rd grade, 27 years ago, and I've had headaches, and issues breathing through both nostrils at any point in time. That's where I'm at. Haven't used the CPAP in... god, I don't know, 3 years now?
[Tiffany] It's a BiPAP though, you said?
[Erik] Yes, it's a BiPAP. I was never able to, honestly, have it on for more than 2 hours. I'd either wake up with it off, or I'd rip it off, wake up, try to put it back on, and wouldn't be able to fall back asleep. It was always painful, it was always difficult. It has the feature where it ramps up the pressure over the first 30 minutes. That would help me get to sleep, but I would not be able to sleep with it on at full power.
[Tiffany] What kind of mask is it? Is it full-face?
[Erik] I've tried every mask that's out there. I've tried the nasal pillows. I've tried the nose only. I even shaved my beard and did the full-face, which- oh god, I hope I don't ever have to do that again.
[Tiffany] Yeah, I hope you don't, either. We can work around it.
[Erik] All right, great!
[Tiffany] Basically, I think that we could help you, because what we do here at ADVENT is not only treat sleep apnea and snoring but figure out a way people can comfortably do that. A lot of the time the reason people are not comfortable with the treatment regimen is because they don't breathe well through their nose, like you said. The number 1 reason why people don't tolerate a CPAP mask is because of nasal obstruction. So, there are different options for sleep apnea. I'm assuming because you had BiPAP and you said it was severe, it's actually probably pretty severe. When they put you on BiPAP versus CPAP, you know that still- you know, there are other options, but they may not treat it as well as the BiPAP mask would. But if we got to that point, our goal would be for you to comfortably wear your CPAP or BiPAP mask, leave it on all night and like it. If we can't get you there, we'd talk about the other options for sleep apnea and snoring, which are throat concerns. So really sleep apnea is collapsing of the throat structure, so it's not really the nose, but the nose plays a part. If you don't breathe well through your nose at night, picking one of these options, whether it's CPAP mask or an oral appliance for sleep apnea, it won't work if you're constantly breathing with your mouth open and you can't breathe through your nose. They're kind of tied together.
[Erik] Okay
[Tiffany] So, if you are interested in pursuing some treatment options for that, we can transition you right into your first patient visit right now if you would like to.
[Erik] Sure, yeah, if it's not too much trouble, let's go ahead and do it.
[Tiffany] Okay, typically what I would do is just send you a consent form through the portal that you are logged into right now to do this visit. Basically, just signing consent agreeing to treatment and, you know, we can do that at some point. With a new patient visit I'll actually conduct a physical exam through the video camera and I'm going to take down all your medical history and everything. Then we can figure out a plan of action. How long ago was your last sleep study?
[Erik] 6 years, I think
[Tiffany] Okay. We'd probably want to update your numbers.
[Erik] Mm-hmm
[Tiffany] Typically, sleep apnea wouldn't get a whole lot better unless you had a significant change like a surgery on your throat or significant weight loss or something like that. We do want the most recent numbers of how often per hour you're actually pausing so we really know the severity. That will change the recommendation and we want you to know to make the best decision for yourself based on what treatment choice you're going to make.
[Erik] That sounds great
[Tiffany] Okay, so we'll probably actually do the home sleep study.
[Erik] Yeah, that sounds much nicer
[Tiffany] That might be a little more comfortable for you. There's no reason why you can't do a home one. Typically, the reason we do an in-lab one is if we're ruling out insomnia, narcolepsy, restless leg, we can't diagnose that at home. But if it's just obstructive sleep apnea, we can do the home one.
[Erik] Oh great.
Part 3 - Exam & Plan
[Tiffany] Any history of any surgery?
[Erik] No, I think the only surgery I've had is wisdom teeth removal
[Tiffany] Okay. Any other medical issues that we need to know about?
[Erik] I don't think so.
[Tiffany] And you never had your tonsils out or anything like that?
[Erik] No.
[Tiffany] Okay. Have you smoked cigarettes ever?
[Erik] Yeah, I smoked from 18 to 23, so about five years. I quit in 2007, I think.
[Tiffany] Did you try any over-the-counter stuff for your nose? Nasal sprays? Anything like that?
[Erik] I used to, but then I had kind of a bad experience where my nose was pretty much completely shut without using the nasal spray. I don't remember which brand it was. It was it was pretty gnarly, so I haven't gone back to those in years.
[Tiffany] So you were able to wean yourself off of it?
[Erik] Yeah, yeah, one nostril at a time.
[Tiffany] No allergy sprays like Flonase or anything like that?
[Erik] No, I never really got into that. I actually didn't really experience any seasonal allergies, just that general difficulty in one nostril at a time, but that changed a couple years ago. I now do get seasonal allergies.
[Tiffany] Okay. The main reason why people don't breathe through their nose well is chronic inflammation over the course of time. Those nasal decongestants kind of restrict the tissue and constrict the blood vessels in the turbinate structures in the nose. It pulls them back temporarily, but then, when it wears off, you can get even more swelling than before, which is how people get dependent on them. But the anti-inflammatory sprays like the Flonase, which are the steroid sprays, those are good, and you can use them for a long time without having any sort of rebound reaction. So that's something we would want to consider getting you on now. Moving forward, because if you would end up having a procedure on your nose, we'd have you using it anyway. It's anti-inflammatory and it's good to try that to see if that helps. Do you get a lot of sinus infections or a lot of drainage or is it mostly just you can't breathe through your nose?
[Erik] Mostly just trouble breathing through my nose. For most of the year, I'm flipping from one side to the other in bed just to get one working and then get the other one working. Yeah, it's just switching back and forth.
[Tiffany] That is common when you have inflammation. The turbinates can be swollen. Those are those tissue structures that act as humidifiers in each nostril and when you lie down, gravity kind of pulls the blood into them so they get big. When you sleep on one side, one will get big and then you switch and the other will get big, but they shouldn't be blocking you off completely, though. That means that baseline, they're probably more inflamed than they should be. The other reason is typically the turbinates, the septum-which is the middle part of the nose-can be deviated one way or the other if you've had a nose injury or sometimes people just are born like that. Typically, you'll notice one side is worse than the other consistently if that's the case. Also, the sinuses themselves- so if the sinus openings are narrow and you don't get good aeration through the sinus cavities, then the lining of the sinuses can become inflamed thus inflaming the entire nose. Sometimes it is linked and even though you don't feel like you get sinus infections, truly there is chronic inflammation in there and having narrow sinus openings can cause that feeling of congestion. Those three things can play a part. The ways to manage that are medical management, which you kind of tried in the past with the decongestants. We'll add some steroid sprays and see if that helps, although I don't know if it's going to at this point if it's just been going on for years. Then the next step is to do imaging of the sinuses and decide if there is a way to open your nose and sinuses up with a procedure to get you breathing better through your nose, then go and treat the sleep apnea.
[Erik] Okay, great.
[Tiffany] I want to do a quick exam on you if you can just open your mouth to the camera for me. Perfect. Can you stick your tongue out tilt your head back just a little? Say, "Ah."
[Erik] Ah.
[Tiffany] You do have a pretty narrow airway in there. You just have kind of like a smaller jaw and mouth.
[Erik] Yeah, and a fat tongue.
[Tiffany] It is narrow back there so that's kind of what's going on with sleep apnea. It's fine when you're awake, but then it will collapse when you relax at night. The other thing I need you to do is just kind of pull on your cheek so you're kind of pulling it away, pulling your nostril out, head back just a little bit big breath. Through your nose.
[Erik] That makes sense [laughs].
[Tiffany] Good. Can you do the other side. Big breath. Do you notice improvement in your breathing when you pull like that?
[Erik] A little bit.
[Tiffany] Okay. That's kind of our way through a virtual visit* our way to test the turbinates because when you pull on your cheek, you're actually on the inside pulling the turbinate away a little bit and giving yourself more room. So, if you do notice an improvement, it's likely you do have bigger turbinates that are inflamed. At some point we would take a look in there and do imaging anyway, so we would actually be able to see. We do have to try medical management first-insurance does require us to try that before just jumping to a procedure. Medical management does include the nasal sprays, as well as a course of antibiotics if you have not been on any antibiotics in the last year for any like upper respiratory issues. Have you been on any antibiotics?
[Erik] No.
[Tiffany] Okay. Each insurance has a different requirement for what they want you to try before you can go get an imaging of your sinuses and a procedure.
[Erik] Okay
[Tiffany] So that will change the length of time you have to try this stuff for.
[Erik] Gotcha.
[Tiffany] You are going to have to try a course of the antibiotics for sure, at least one course, and the nasal spray. Humana requires 12 weeks of nasal spray-
[Erik] Oh wow.
[Tiffany] And two different courses of antibiotics and then if you still don't breathe through your nose, then you can go. Anthem just requires one course of antibiotics and four weeks of nasal spray.
[Erik] Okay.
[Tiffany] Both of them require if you feel like you have allergies you have to get tested for allergies, which we do. It's simple it's a simple skin test we do at the office. In the meantime, while we're getting you set up with all this stuff, we can get you scheduled for that, too.
[Erik] Great.
[Tiffany] The other thing is a sleep study. We'll get you set up with a take home sleep study that will be sent to you. You wear it one night, unless they advise you to do two nights, but usually it's just one night, then you send it back. Once we get the results, we can go over that just to confirm where we are and then we'll know where your numbers are. We'll still be trying to fix your nose first and then we'll address the sleep apnea. We just want to do it in the right order so we're not giving you another thing that's not going to work for you.
Tune in next week for my home sleep study!