Trouble sleeping: Finding the right solution

With nothing working well and his sleep apnea getting worse, this father decided to try a newer surgical option.
August 15th, 2018
James Morales and his kids.
James Morales and his kids. Photo courtesy of James Morales.

Not getting enough sleep on a consistent basis wears on the body and mind. Just ask any new parent or someone with sleep apnea.

Just ask James Morales.

“I would wake up and feel exhausted,” said Morales, 41. “I didn’t want to do anything. I’d come downstairs and sit. At work, I had trouble focusing and concentrating. Lots of people were relying on me and asking me questions, but I just couldn’t think.”

When Morales was in his early-30s, his wife, Farhana, started noticing that her husband wasn’t sleeping well.

“He had always snored, which was difficult for me, but you get used to it,” she said. “But I’d wake up, and he’d have these weird episodes where he’d be breathing and snoring, and then there would be nothing — that’s what scared me. That’s when we knew it was serious.”

After talking to his physician, Morales was referred to the sleep clinic near his home in Aurora for a sleep study.

Sleep studies are done in a sleep lab, which looks like a small bedroom but with monitoring equipment. A person arrives a few hours before their normal bedtime and is monitored throughout the night. For those who turn out to have sleep apnea, the study yields an Apnea-Hypopnea Index score, which is the number of times per hour a person stops breathing for at least 10 seconds and shows a decrease in blood-oxygen levels. Someone with severe sleep apnea has a level greater than 30.

Alternatives to CPAP seminar

For those who are unable to use CPAP, a seminar led by Dr. Katherine Green, medical director of the UCHealth University of Colorado Hospital Sleep Center, will cover treatment options like Inspire therapy and sleep surgery.

February 27, 2019
5:30 – 6:30 pm
University of Colorado Hospital
Bruce Schroffel Conference Center
RSVP here: https://www.uchealth.org/events/events/alternatives-to-cpap-seminar/

“Around then I was about 35,” Morales said.

That was more than a decade ago. Fast forward to 2016, and Morales’ number had jumped to more than 70. But then fast forward to the present, where Morales hovers around an 8.

What’s changed? Let’s start again at the beginning.

Remedies for trouble sleeping

After his first sleep study, Morales began using what most people with sleep apnea are prescribed: a CPAP, or continuous positive airway pressure machine. The machine supplies constant and steady air pressure through a hose and mask, and is effective in treating sleep apnea more than 90 percent of the time. That’s if the person can tolerate it.

James Morales and his daughter, Layla, in front of their home in Aurora.
James Morales and his daughter, Layla, in front of their home in Aurora. Photo courtesy of James Morales.

Morales fell into that 10 percent who can’t.

“James slept worse with CPAP and was relying on sleeping pills to tolerate the machine,” said his sleep specialist, Physician Assistant Anne Lassiter with UCHealth Pulmonology in northern Colorado. “The majority of patients will eventually adapt to CPAP if they are monitored closely and given support beyond simply prescribing equipment. That wasn’t the case for James.”

Instead of turning a corner with CPAP, Morales had instead hit a wall.

“So for two to three years I didn’t do anything,” he said. “I just tried to sleep the best I could.”

The concern in Farhana’s voice was evident.

“He was in the Army Reserves for quite a few years during this time, working as a mechanic,” she said. “I worried about his focus; I worried about him injuring himself.”

A new option

Then in 2014, Morales read about the FDA’s approval of a device called Inspire, which is implanted into the chest much like a pacemaker but uses electrical stimulation to keep the tongue from obstructing the airway during sleep.

He brought it up to his wife, and she encouraged him to make sure they’d exhausted their options before turning to surgery.

“It is major surgery, and I was very scared,” she said. “I’m all about yoga and relaxations. I wanted to make sure we’d tried everything.”

So, Morales went back to CPAP. For almost a year, he went back and forth to the medical supply store, trying different masks and machines, frustrated. And during the process, he learned he had a deviated septum, but even correcting that did not allow him to tolerate CPAP.

Next was Provent Therapy, a prescription treatment that is applied to the nostrils, using the power of one’s own breathing to hold the airway open, according to its website. Morales said he showed some success with this treatment, but the small, adhesive, disposable devices would always end up stuck to his pillow instead of his nose.

James Morales with his family at the top of the York Minster’s Central Tower in England.
James Morales with his family at the top of the York Minster’s Central Tower in England. Morales said he would have never had the energy to climb the 275 steps to the top if it weren’t for Inspire. Photo courtesy of James Morales.

“There were a few things that would work for a bit, but everything was temporary,” Farhana said. “Then we were back to square one, listening to him struggle again.

“I saw his energy levels go downhill. He was having trouble remembering things. His mood changed. He was working off of very little sleep,” she continued. “Being a person who loves sleep, I can’t imagine going even a few nights without it, and he’d been going through this for years.”

Let’s talk ‘Inspire’

James decided to talk to his wife about Inspire one more time. They did the research and found that UCHealth Poudre Valley Hospital was the only location on the Front Range with a trained otolaryngologist and surgeon, Dr. Matthew Robertson, doing the procedure.

“He had a good success rate and track record, and there was nothing else that James could do that didn’t require other major surgeries,” Farhana said. “My logical mind was like: let’s try it.”

UCHealth University of Colorado Hospital’s Comprehensive Lung and Breathing Program in Aurora has since hired Dr. Katherine Green, an otolaryngologist and fellowship-trained sleep medicine specialist and surgeon, to provide patients at UCH with Inspire therapy.

In early 2016, Morales talked with Cindy Crosby, manager of UCHealth Sleep Lab – Poudre Valley Hospital, and the two of them began the process.

Is Inspire right for you?

Morales went through the initial screening to make sure he met the FDA qualifying criteria, which include a body mass index of less than 32. The team reviewed his sleep study result — he had to have a new study done since it had been several years since his last one — and then a procedure was done to determine if the back of the throat was collapsing in a way that Inspire could treat. It was at that time that he was introduced to Lassiter, who followed him through the whole process.

“Dr. Robertson, Anne (Lassiter) and Inspire were amazing at this portion of the process,” Morales said. “They prepared me for the lengthy insurance process but were encouraging that eventually, it would go through.”

It took almost a year to untangle the ropes and restrictions of his insurance, but finally, they approved the procedure in early 2017, and within a month, Morales was scheduled for surgery.

James Morales swimming in a cave in Mexico.
James Morales enjoys a recent trip to Mexico. With sleep apnea not being addressed, traveling was exhausting for Morales. But after his Inspire procedure, he’s got the energy to enjoy his travels with his wife and family again. Photo courtesy of James Morales.

The big day

“I was a little worried about the surgery, but for me, it was more excitement,” he said. “At this point, I wasn’t getting any sleep. I was losing track of things, having trouble driving — even driving to the doctors’ appointments was hard. It was exciting knowing we were going to fix these issues.”

In the past several years, Morales had become so tired that he had stopped doing a lot of the things he used to do with his family. Weekend snowboarding trips with the two teenagers who still lived at home had stopped. Projects around the house were not getting done. Thoughts of heart attacks loomed in the back of his mind.

On an early morning in July 2017, Morales and Farhana arrived at PVH.

In the 90-minute outpatient procedure, a small battery was implanted in Morales. From that device, a wire that senses his natural breathing patterns is directed to a nerve in the tongue and another to the rib cage area. When he breathes in, an electrical stimulus is delivered to his tongue that gives it tone and prevents it from falling backward and obstructing his airway. The device is controlled by a small hand-held sleep remote that can turn on the device at night and off in the morning when he wakes.

Morales said his recovery took about a month. The first few days he couldn’t use his right arm. Surgeons implant Inspire on the right side in case the patient ever needs a cardiac pacemaker, which goes on the left side. Farhana took good care of Morales while his arm was in a sling, he said. By week two, he was mobile, out of the sling and doing things, but it wasn’t until about week three that he felt fully recovered.

At that time, he returned to the sleep center for the calibration of his device.

“Not unlike when a patient has a sleep study done to allow technologists to target the best CPAP pressure, calibration of the Inspire unit is done to ensure the best level of stimulation is occurring,” Crosby said. “That allows for maximum treatment of apnea as well as an opportunity to explore settings that can make its use most comfortable.”

James Morales walks his daughter down the aisle
James Morales walks his daughter down the aisle during her Star Wars-theme wedding. Photo courtesy of James Morales.

“This is when I knew I made the right choice,” Morales said. “And once they figured out where the device needed to be set at, I didn’t have any issues.”

To sleep like you

“Everything has changed,” Morales continued. “Now I wake up and feel like I can do something. I’m going back to school, which I was afraid of doing before because I couldn’t focus. I go up snowboarding without worrying about falling asleep on the way home. And I’m headed to Italy, and then Yellowstone the next month.”

And in the year since the procedure, Morales’ daughter completed her first year of high school.

“There is no way I would have survived my daughter’s first year of high school if I didn’t get this done,” he said. “I was driving her everywhere.”

And James also got to walk his other daughter down the aisle recently. “I could have missed that,” he said.

“Inspire not only saved my life, but it has changed my entire life,” he continued. “I feel like an actual person now, and I told my wife, ‘I finally get to sleep like you do.’”