Dr. Barry Dicicco, M.D., F.C.C.P., Pulmonary and Critical Care Specialists of Northern Virginia, P.C. interviewed by Emilie by mail, responses written Mar. 15, 1999. All questions are from the TQ team. All answers are quoted from Dr. Dicicco. Some may be excerpts.
Purpose: To learn a human side of the experience of a doctor in the area of sleep medicine.
1. Q. How did you get interested in Sleep Medicine? What education or experience did you have to have for this specialty?
1. A. "I became interested in sleep medicine while studying pulmonary medicine as a fellow at Georgetown University. [This] ... involve[d] the diagnosis and treatment of respiratory disorders and [is]... focused on the control and regulation of breathing; sleep medicine was a natural avenue of research for me since many patients with sleep disorders have problems maintaining oxygenation and proper breathing while asleep . . . . I met on a daily basis in the early morning hours with the directors of the sleep laboratory, Dr. Samuel Potolicchio and Dr. Richard Waldhorn, and learned to interpret sleep studies."
2. Q. How long have you been involved in sleep medicine?
2. A. "...Since 1983, approximately 16 years."
3. Q. What are the most common sleep complaints you have seen in your patients?
3. A. "... Daytime hypersomnolence, or sleepiness during the day, and patients who have loud snoring and breath-holding at night. We also evaluate patients with leg movement disorders, insomnia , and narcolepsy . Most of our patients are adults, although occasionally we evaluate pediatric patients."
4. Q. Have you seen any patterns of sleep complaints among patients of different gender or age? Have you noticed a change in patients' complaints [over] the years during your practice?
4. A. "Patients' complaints had been relatively similar during the last five or ten years. Now, the knowledge of sleep-disordered medicine is much more widespread . . . . We are now seeing patients who have already been diagnosed and are returning for a follow-up assessment either to better guide their treatment, such as nasal CPAP , or who would like to be reassessed after losing a significant amount of weight and are wondering whether they still need the nasal positive pressure mask to treat their obstructive sleep apnea ."
5. Q. What do you look for in the patient's sleep data? Do you look at the computer version, paper printouts, or just the lab report summary . . . ?
5. A. "...16 different channels of monitoring. Primarily, we look at brain waves to assess for the different stages of sleep, oxygenation, and air flow. We also look at chest and abdominal wall movements, heart rhythm, the presence of leg movements in the lower extremities, muscle movement in the chin and the presence and intensity of snoring. As a physician/director of the lab at Fair Oaks Hospital and Prince William Hospital both in Virginia] where we have sleep labs, I directly interpret on the computer screen all the sleep studies. I am assisted in this by my associates, Dr. Thomas LoRusso and Dr. Richard Swift. We look for evidence of breath-holding, oxygen deprivation, and leg movement activity. We also assess the various stages of sleep, particularly looking for the onset of rapid eye movement sleep .
6. Q. How do your tests vary for different patients depending on their complaints and symptoms?
6. A. "If patients have possible narcolepsy , we do a multiple sleep latency test (MSLT) during the day in which the patient takes four or five consecutive naps while we look for the presence of absence of ...[REM] sleep."
7. Q. How pronounced or severe do results have to be before you decide to try certain mechanical or surgical treatment options?
7. A. "The decision to place patients on mechanical therapy, i.e., a nasal CPAP mask, is based on not only the severity and frequency of sleep-disordered breathing, but also the degree of desaturation, the patient's age, overall medical condition and other risk factors. We also discuss with the patient in terms of their lifestyle and other treatment options."
8. Q. Are there any sleep disorders for which there aren't yet treatments? What do you suggest to these patients?
8. A. "There are many sleep disorders where there are no good specific therapies. Sleep apnea is currently treated with a nasal CPAP mask and unfortunately, we do not have specific medications to cure this problem with the exception of patients who have an underactive thyroid in which case replacement of the patient's thyroid hormone may be curative, or certainly helpful, in decreasing the degree of sleep-disordered breathing.
Patients with delayed phase sleep syndrome , so-called 'night owls,' who have difficulty awakening in the morning (a common problem in adolescence) do not have any standardized therapy. For these patients, we sometimes suggest light therapy in which the patient sits in front of a standardized high-intensity light source in order to arouse the brain and better synchronize the patient's brain.
9. Q. Do you see sleep problems common within families? Which disorders seem to be genetic?
9. A. "Sleep disorders tend to run in families and there are familial patterns. This is probably related in the way people are constructed in terms of upper airway anatomy. We do not know of any specific genetic marker ... [linked] with obstructive sleep apnea . However patients with narcolepsy have certain markers which can be found, so-called 'HLA typing,' which are specific for the diagnosis of narcolepsy .