Dr. Neale Lange is a leader in sleep medicine who started his medical training in South Africa and now practices Pulmonary and Sleep Medicine for UCHealth in Denver.

Sleep plays a crucial role in cognitive behavior and physical well-being but is often times taken for granted. As Dr. Neale Lange puts it, many people have been taught or trained to devalue sleep in an effort to maximize the time awake to study, get caught up on work, or complete other tasks¹. However, research over the years has demonstrated that the toll sleep deprivation plays on the body is significant. Sleep deprivation can lead to impairment in memory, cognition, and emotion, and can lead to chronic medical conditions such as diabetes, heart disease and cancer². It is also thought that sleep deprivation and hypoxemia are associated with white matter disease in the brain and deep slow wave sleep, is what fixes it⁴.

Furthermore, Dr. Lange states that sleeping at altitude carries its own risks. Sleeping at altitude, where there is less oxygen in the air, can cause overall poor sleep quality, increased awakenings, frequent arousals, marked nocturnal hypoxia and periodic breathing.^. Additionally, sleeping at altitude can negatively impact our sleep architecture, increasing the amount of light sleep and decreasing the amount of deep slow-wave and REM sleep which plays a key role in memory creation, retention and emotional control and personal behavior³.

In hopes to defining a person’s sleep at altitude, Dr. Lange started a sleep lab in Summit County at St. Anthony Summit Hospital, which, as he put it, “opened a can of worms” when he saw how sick and complicated patients sleep apnea cases were. Time and time again, he saw that when patients who were struggling with sleep apnea were given 2L of supplemental oxygen by nasal cannula, the apnea improved. Additionally, those patients with sleep apnea who descended around 4,000 ft to Denver have improved saturations but may still have sleep apnea. His facility study included baseline tests at two hours without oxygen and then two hours with oxygen while a person slept. He found that although the apnea improved in many, improvements in sleep itself did not always follow.

This left him with the question of: How do we measure “good sleep?” Well, as he states, it is not that simple. Though the obvious answer may be to turn to medications to determine good sleep, this can be misleading. Medications have an amnestic effect on people because when they wake up in the morning, if their memory is blank, they feel that they have had a good night’s rest. But in reality, this is subjective. The true data collected during sleep is objective, so to answer his question of measuring sleep, he turns to a tool of cardiopulmonary coupling (CPC). This tool, called a SleepImage Ring, looks similar to an Apple Watch and is worn around a patient’s finger throughout the night. Using Bluetooth technology, data is collected and transferred through a smartphone for analysis, providing the patient with a vast amount of data about their sleep.

The SleepImage System is the only FDA approved medical grade technology with the simplicity of a consumer device on the market for use in both children and adults. It is intended for use by a healthcare professional to establish a patient’s sleep quality and aid in evaluation and clinical diagnosis of sleep disorders and sleep disordered breathing, or SDB. It uses CPC technology which is “based on calculations and spectral analysis of cardiovascular- and respiratory data” collected during sleep using continuous “normal sinus rhythm ECG- or PLETH (Plethysmogram from a PPG sensor) signal as the only input requirement.” The output metrics from the SleepImage System include “sleep duration (SD), total sleep time (TST), wake after sleep onset (WASO) and sleep quality (SQI) and sleep disordered breathing (SDB) related output metrics that include an Oxygen Desaturation Index (ODI), an Apnea Hypopnea Index (sAHI), a Respiratory Disturbance Index (sRDI), Central Sleep Apnea Index and the Sleep Apnea Indicator (SAI) that is derived from Cyclic Variation in Heart Rate (CVHR)⁶. With a PLETH signal including saturations, the SDB data conforms with the American Academy of Sleep Medicine AHI scoring and severity definitions.” Additionally, we can determine how long a patient spends in various sleep stages, including stable, unstable and REM sleep, determine apnea events, and autonomic nervous system activity. The data is generated and presented on the SleepImage Quality Report (shown below). The ring and report are designed as such where you can do individualized, precise sleep medicine. It is true when Dr. Lange says “the devil is in the details” referring to the vast amount of information that can be analyzed from this device during one night of sleep.

Currently, the gold standard to monitoring and diagnosing sleep disorders is polysomnography, also known as a sleep study, which records certain body functions as you sleep to determine brain activity, oxygen, heart rate, breathing, as well as eye and leg movements⁵. It can detect types of sleep apnea; however, this comprehensive test is typically done during an overnight stay in a hospital or other sleep center, which presents a disadvantage. The disadvantage to polysomnography is that it takes people out of their natural sleeping environment, is costly, and time consuming, which deter a large portion of people from partaking in sleep studies.

Dr. Neale Lange explains that this device can change the way we look at our sleep and may provide better insight into a person’s sleep on a greater scale due to the ease of wearing the device over multiple nights, compared to spending one night in a sleep lab for a study. A study done on 65,000 users indicated that there is added benefit to multi-night testing as compared to single night testing. Testing for sleep apnea on only one night has been shown to vary from night to night, indicating that single night testing potentially misclassifies 20% of people⁷. This device provides the ease of multi-night testing for patients, which is a significant advantage and increases accurate diagnosis of sleep disordered breathing. To Dr. Lange, “it is about individualized patient care” and evaluating “the person sitting in front of [him]” which makes this device so valuable. Dr. Lange states that, “living at altitude is a particular challenge, and if people are thinking ahead,” instead of wondering, “how long do I want to live at altitude,” a better question would be, “how can I invest in brain wellness.”

In summary, sleep deprivation, especially at altitude, is an important focus that people should not overlook. At Ebert Family Clinic in Frisco, one of the most important questions asked is, “how did you (or your child) sleep last night?” Now, with the SleepImage Ring, we can objectively evaluate our patient’s sleep which can aid in the diagnosis and management of various conditions.

References

1. South African Dental Association. (2021, November 25). The sleep disorder spectrum: Mouth breathing to Osa – Dr Neale Lange (WEB126). YouTube. Retrieved December 5, 2021, from https://www.youtube.com/watch?v=agZruGNfFNI
2. Irish, L. A., Kline, C. E., Gunn, H. E., Buysse, D. J., & Hall, M. H. (2015). The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep medicine reviews, 22, 23–36. https://doi.org/10.1016/j.smrv.2014.10.001
3. Wickramasinghe, H., & Anholm, J. D. (1999). Sleep and Breathing at High Altitude. Sleep & breathing = Schlaf & Atmung, 3(3), 89–102. https://doi.org/10.1007/s11325-999-0089-1
4. Voldsbekk, I., Groote, I., Zak, N., Roelfs, D., Geier, O., Due-Tønnessen, P., Løkken, L. L., Strømstad, M., Blakstvedt, T. Y., Kuiper, Y. S., Elvsåshagen, T., Westlye, L. T., Bjørnerud, A., & Maximov, I. I. (2021). Sleep and sleep deprivation differentially alter white matter microstructure: A mixed model design utilizing advanced diffusion modelling. NeuroImage, 226, 117540. https://doi.org/10.1016/j.neuroimage.2020.117540
5. Mayo Foundation for Medical Education and Research. (2020, December 1). Polysomnography (Sleep Study). Mayo Clinic. Retrieved December 25, 2021, from https://www.mayoclinic.org/tests-procedures/polysomnography/about/pac-20394877#:~:text=Polysomnography%2C%20also%20called%20a%20sleep,leg%20movements%20during%20the%20study.
6. MyCardio LLC. (2021, November 24). Introduction to sleepimage®. Retrieved December 10, 2021, from https://sleepimage.com/wp-content/uploads/Introduction-to-SleepImage.pdf
7. Lechat, B., Naik, G., Reynolds, A., Aishah, A., Scott, H., Loffler, K. A., Vakulin, A., Escourrou, P., McEvoy, R. D., Adams, R. J., Catcheside, P. G., & Eckert, D. J. (2021). Multi-night Prevalence, Variability, and Diagnostic Misclassification of Obstructive Sleep Apnea. American journal of respiratory and critical care medicine, 10.1164/rccm.202107-1761OC. Advance online publication. https://doi.org/10.1164/rccm.202107-1761OC

Catherine Atkinson is a second-year Physician Assistant student at Red Rocks Community College in Arvada, CO. She was born and raised in Colorado where she has lived her entire life. She received her undergraduate degree in integrative physiology from The University of Colorado- Boulder. Prior to PA school, she was an ophthalmic technician at Colorado Retina Associates. In her free time, she loves cooking, skiing, playing golf and spending time with her family and friends.