BOWLING GREEN Michael Zachek, MD, has seen the evolution of sleep medicine from the 1990s until today. He has a profound, patient-based overview of the specialty and the intimate connection between obstructive sleep apnea (OSA) and a wide array of cardiovascular and pulmonary problems. Talking with Zachek about sleep disorders and heart, lung, and vascular issues opens one’s eyes to the timeless advice of the benefits of getting a good night’s sleep.
Boarded in internal, pulmonary and sleep medicine, Zachek received his undergraduate and medical degrees from Georgetown University. He took his residency at Duke University and completed a fellowship through his US Air Force commitment at Scott Air Force base at Washington University in St. Louis. He followed that with pulmonary and critical care specialty training via the US Air Force at Wright Patterson in Dayton, Ohio.
Since 1986 he has practiced in Bowling Green, Kentucky at the Graves Gilbert Clinic (GGC). He is also medical director at the Physicians Center for Sleep Disorders, Owensboro Health Sleep Center, The Sleep Center at Ohio County Hospital and Twin Lakes Regional Medical Center. He is on sleep center staff at Good Samaritan Hospital, Lexington and TJ Samson Hospital, Glasgow, a site visitor for the American Academy of Sleep Medicine, a Gold Standard Scorer AASM Inter-scorer Reliability Board member, and past president of the Kentucky Sleep Society.
It’s wonder he gets any sleep at all.
Evolution in Sleep Medicine
Zachek recalls joining GGC because he wanted to “focus on what I do best, which is medicine.” Kentucky, with its coal mines and high tobacco use, was a patient-rich environment for the young pulmonologist. The small town of Bowling Green and a multi-specialty practice appealed to him. As Bowling Green has grown, so have Kentuckians. “Now, so much of our population is overweight that my practice has been overwhelmed with patients that have sleep apnea,” he says.
In the 1990s diagnosis and treatment of sleep disorders involved overnight sleep studies and several months of patients waiting for results and treatment. The current paradigm of obvious OSA is to evaluate the patient, arrange for a simple home breathing recording (Home Sleep Apnea Test), and place the patient on initial therapy the morning after their test. “Modern technology, including phone apps that allow patients to monitor his or her progress, modems that allow clinicians remote access to CPAP data and permit modifications to the PAP prescription, along with smart PAP devices that automatically adjust pressures, have revolutionized the care of OSA,” says Zachek.
Greater acceptance of telemedicine is the future of his specialty, says Zachek. “Sleep medicine is well-suited to remote evaluation and treatment in rural areas with limited access to specialists. Our biggest impediment to timely care now is third-party payer requirements for pre-certification and authorization for machines and devices,” he adds.
Patient Population & New Treatment Modalities
In past years the typical patient with OSA was the hypertensive, obese, middle-aged male. Like many medical conditions, when physicians started to look for OSA in other populations, they found it. Zachek says he now sees children with andenotonsillar hypertrophy. Pediatric sleep apnea is a common cause for lack of attention and focus in school, and many more children are obese. Women are increasingly recognized as having OSA, especially post-menopausal women. Special populations, with craniofacial abnormalities, also have OSA.
In addition to advanced PAP (positive air pressure) devices (CPAP, BIPAP, auto PAP, servo ventilators, etc.), there are advancements in dental devices and surgeries. Dentists can fashion mandibular advancement devices that are frequently a great alternative to PAP. They especially benefit patients with retrognathia, when the lower jaw is set back much farther than the upper jaw. Unfortunately, insurance companies are often a barrier as many dentists are not familiar with billing for medical devices and are not in network.
Surgery has been offered for OSA for years. Some of the earlier surgeries seemed logical, but the results were not particularly good. However, tonsillectomy and adenoidectomy in children is the treatment of choice and is very effective, unless the child is obese. “Bariatric surgery for our obese adult population is a game changer for many patients,” says Zachek. “It helps their orthopedic, cardiovascular and endocrinologic problems, as well as improving or curing OSA.”
Another new and interesting surgical approach is the hypoglossal nerve stimulator. This device is now FDA approved for specific populations. The device is basically a “pacemaker” for the tongue, protruding the tongue with each inspiration. If the patient has the proper anatomy and is not too heavy, this device can be an alternative to PAP and dental devices.
“What we have learned in the treatment of OSA is that patients are individuals, and that a unique approach must be taken to the treatment of these folks,” says Zachek.
The Cardiovascular Connection
When a patient experiences an obstructive apneic event, the cardiovascular system is stimulated because increased sympathetic nervous system tone is required to clear the airway and alert the brain. Over the past two decades the relationship of OSA and hypertension has become clear. “OSA is a cause of hypertension, and treating OSA helps control blood pressure,” says Zachek.
Similarly, with arrythmias like atrial fibrillation, Zachek says, “If we are to successfully avoid recurrent bouts or paroxysmal atrial fibrillation, effective OSA treatment can be helpful. Patients with heart failure, with reduced ejection fraction treated with optimal medical therapy can benefit from OSA treatment. Pulmonary hypertension due to chronic nocturnal hypoxia, a consequence of OSA, can be reversed with PAP. Population studies seem to demonstrate that addressing OSA successfully in patients who have experienced myocardial infarction, CABG, stents, sudden death-like events, and strokes, improves outcomes.”
It surprises Zachek that even after 25 years of working in the field, he sees patients with obvious, severe undiagnosed OSA. In many circumstances, the patients have been advised by their primary care providers to seek medical attention, but have not followed that advice because of misconceptions regarding the expense of diagnosis and treatment. “By simplifying the entire process and lowering the cost, we find that we are serving a much larger population, successfully,” he says.