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Interviewer: Picking the right mattress, according to a sleep expert. That's next on "The Scope."

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Interviewer: You know, it can be a bit of an overwhelming proposition when you go into the furniture store and there's all those mattresses and you only have maybe an hour or so to pick the one you'll be sleeping on for the next 10 years or more. I mean, like, how firm, how soft? What's better, a spring-based or a memory foam mattress? Lots of questions, and hopefully we're going to answer some of those. Dr. Milton Chua's a sleep expert at University of Utah Health, and he's going to help us through this process. So, my very first question is what kind of mattress do you have?

Dr. Chua: What I have at home is just a normal, whatever-you-get-from-Amazon memory foam.

Interviewer: Oh, it's a memory foam, okay.

Dr. Chua: Yes.

Interviewer: So let's kind of break down, you know, should I just get that mattress? Is the memory foam the . . . this could be the shortest interview ever.

Dr. Chua: It depends on what your comfort is, what you find comfortable. And there are some studies trying to . . .

Interviewer: Kind of define that.

Dr. Chua: Define what comfort is. So . . .

Interviewer: Yeah, because it could be something different to each person.

Dr. Chua: Right, well, there's a study that was done, showing that the most comfortable position when you're sleeping is that it is something when your spine is similar to a position when you're standing. So, when you're standing straight, your spine curvature should be the same as when you're lying down on your back. So if you pick a too soft of a mattress, your spine would sag. If you pick a too firm of a mattress, it would be too straight. Then you'd get back pain.

Interviewer: Okay, and does that change from person to person?

Dr. Chua: It does. I mean, it depends on your body weight. It depends on your muscle tone. Because if you do a lot of exercise, you get more muscle tone and really that's . . .

Interviewer: Does that help you stay in that sleep position better?

Dr. Chua: Well, again, it depends on the mattress that you have.

Interviewer: Wow, okay. So let's go back quickly to good sleep quality. What exactly does that mean? Does that mean the ability to sleep through the night, or does that mean not waking up with aches and pains? Does that mean both? Is there some additional stuff there?

Dr. Chua: So, when we're looking at sleep in a sleep lab, we're looking at sleep stages and, you're going through different stages of sleep, light stage up to deep stage. And then you have the rapid eye movement. When we say that you're getting good sleep quality, it means that you're not waking up a lot of times during the night. So most of the time when we're waking up at night, it's to maybe change position, or it's because we're having some trouble breathing, or it's just comfort or we need to go to the bathroom. So we try to minimize the amount of arousals that we have during the night. And at least having a good, comfortable mattress, and the one that keeps your spine in that position would be comfortable.

Interviewer: Okay, so I'm in the mattress store. I'm taking into consideration I want to keep my spine like it is when it's standing, taking into consideration my weight, my fitness level. When I'm lying on those mattresses in the store, trying them out, what should I look for?

Dr. Chua: You know, it's funny. When I did my research on these mattresses, I went to different mattress stores and tried out myself, because I didn't know anything about this myself. So I went to some mattress stores. I didn't find anything really standing out. And then I went to one of these stores where they have these adjustable mattresses where they can make it soft or firm.

Interviewer: Those air mattress-type things.

Dr. Chua: The air mattress-type things.

Interviewer: Not mentioning any brands, but . . .

Dr. Chua: Not mentioning any brands. But it's amazing how different it feels when you first lay on these mattresses and they have pressure points that they look at when you lie on the mattress. And they're onto something for sure. So they look at the pressure points and make sure that you feel an even pressure throughout your body.

Interviewer: Okay, so regardless of the type of mattress, whether it's one of these air-type mattresses or a memory foam or a traditional spring, one of the things you're looking for is just kind of a consistent . . . what was your verbiage again?

Dr. Chua: Even pressure.

Interviewer: Even pressure throughout the body.

Dr. Chua: Throughout the body.

Interviewer: That's what you're kind of feeling for.

Dr. Chua: That's one, yes.

Interviewer: Okay, because when you go into the mattress store, like, it's kind of unfair because you're trying it out for only a few minutes at a time. You don't know how the cumulative effect is going to affect you. I think the tendency is to pick, "Oh, this one feels the most luxurious," but that might not be the best choice. But trying to feel for a consistent pressure throughout the whole body is what you're feeling for. Are you getting that support all along the whole body? Okay. What else should I look for?

Dr. Chua: So one other thing is, make sure that the mattress is not too cold or warm or absorbs that temperature and just makes it too hot after a while or too cold. It doesn't really absorb that heat.

Interviewer: Got you. So I wouldn't have considered that. What else should I look for as I'm laying on that mattress? I suppose I should try out the sleep position that I sleep in on the mattress, whether I'm a back sleeper or a side sleeper.

Dr. Chua: So, again we're looking at what the spine should be at when you're sleeping on your side. And if the mattress is too firm, then you get that poor position.

Interviewer: Yeah, but you should try out whatever sleep position you sleep in, even if it feels a little silly.

Dr. Chua: Yes.

Interviewer: All right. And how long should you lay on a mattress before you kind of start to notice?

Dr. Chua: So one of the reasons why I got a mattress from Amazon or the Marketplace is that they give out, like, a 30-day trial. And then you try it out 30 days. If you feel comfortable, then that's it. If you don't, then they'll pick it up from your house.

Interviewer: Yeah, so regardless of who you purchase from, see if they have some sort of a 30-day trial that you could return it.

Dr. Chua: Right, and I think most mattress stores have that. So . . .

Interviewer: And don't feel badly if you have to take it back?

Dr. Chua: Yes.

Interviewer: Okay. So we've done a lot of talking about mattresses, and there's all these different kinds of mattresses. What about our ancestors? How did they sleep comfortably without all these fancy mattresses?

Dr. Chua: Right, so I get that question all the time and we have this trend trying to go to our roots. Why did our ancestors . . . you know, they survived without mattresses or beds. Really, if you think about it, they did not need beds, or they should not have had beds at that time. If they slept on a bed and they slept for six or eight hours during that time, they would wake up their breakfast or their dinner. So as we evolved, what happened is we get more safe. We build houses, and now we're safer, so we try to look for more comfort.

If you look at beds, even our ancestors had makeshift beds. They put leaves on it. And then there's the evolution of a raised bed to get rid of the vermin on the ground. But if you also look at some of the ancient times, some people used to sleep on an inclined bed so that they're able to jump out of bed right away when the enemy comes in to attack.

Interviewer: All right, so our times have changed quite a bit, meaning our ancestors didn't know eight hours of sleep. Of course, I mean, most of us don't know eight hours of sleep, even though we should, right? They were only sleeping an hour or two at a time, so their needs were very different than ours.

Dr. Chua: Right.

Interviewer: Got you. How long should a mattress last before I need to consider getting another one?

Dr. Chua: It depends. It depends. I mean, if you . . .

Interviewer: Does it come back to that same thing? Once you feel that it's not giving you that even support, then it's time to start thinking about something else?

Dr. Chua: Yes, yes.

Interviewer: It all comes back to that.

Dr. Chua: Right. Oh, and one other thing on that point is you have the expression "sleep tight." So, in ancient times, when they were making beds, they made it on a weave of either leather or maybe a cloth. And when you're sleeping, or before they go to sleep, they tied in those strings tight so that they have that support on their back. So that's where the expression comes from. So when you're saying, you know, "When do you replace the mattress, when it sags?" Replace it.

Interviewer: When you're no longer sleeping tight.

Dr. Chua: Exactly.

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Interviewer: Dr. Stephen Jay Fenton is a pediatric surgeon and also an expert in congenital diaphragmatic hernia. So, most of the time, it's diagnosed before the woman has given birth. So, this diagnosis comes in, what are some considerations that the woman, the mother, the family are going to have to do at this point?

Dr. Fenton: Once this woman has diagnosis they need to be referred to a maternal fetal medicine physician, so someone who deals with high risk pregnancies. And one of the things associated with that is that they need to be followed closely during their pregnancy. One is to ensure the safe delivery of the child and then also in preparation as far as what will happen once the child is born.

I think it's important for the mother to know that this is something that will require treatment for a long time after the child is born. So I typically would say three, four, to six months afterwards, that child will need to be in hospital that takes care of these types of kids. And so sometimes it might require relocation or making sure they have a support system away from their house. For example, if they live quite a bit away from the children's hospital that deals with this specialty, they may need to start thinking about the Ronald McDonald House or finding some other place that they can live.

Interviewer: Wow, so this diagnosis is a serious thing.

Dr. Fenton: Yeah, I mean over the past 10 to 20 years the survival rate has improved, but it still is one of those diseases that takes a lot as far as to treat the child once they're born and then afterwards to help the child continue to grow.

Interviewer: What's the conversation that you have with these families? Take me through that conversation, some of their concerns, their questions, the things that you tell them that are important to consider.

Dr. Fenton: So, after getting past the basic questions of what is a diaphragmatic hernia and how is it treated, the things that I really focus on are we need to find out a little bit more about the child. So, one of the things that we'll get when they come to our office is what we call predictive or prognostic predictors.

So, a lot of times they will have already undergone ultrasounds, several ultrasounds, to look further at the child. One of which is of the heart, so a fetal echocardiogram. We want to know whether the child has a congenital heart disease as well because that does complicate things when the child has not only a diaphragmatic hernia, but has congenital heart disease as well. They are at a much higher risk of not surviving.

And it also limits some of the things we can do, especially as far as the ECMO or the heart lung bypass, if the child has a structural heart defect we can't put them on ECMO. So, the families need to know that.

Additionally we want to know what their chances of going on ECMO are and what their survival ability is. So, we look at these different things. One is the lung to head ratio, which is obtained by the ultrasound. Then the other is the total lung volume which can be obtained by the MRI. And those, depending on what the lungs look like, so the ratio of the lungs to the heads and/or the observe to expect of total lung volumes.

We can give parents the percentage of whether their child is going to require ECMO support and/or what their survivability is. And so the parents, when I talk to them, I almost talk to them much more about the support that the child will receive before and after repair, than the repair itself. Because the repair is really a step and only one of many steps in the care of the kid once he's born.

Interviewer: Wow. So, how do you help parents take all this information that you just talked about, head-lung ratios, and how do you make them make sense of what they should do at that point?

Dr. Fenton: Well, I think it's hard, especially for the initial visit, because a lot of information is given and so we will talk to them upfront and then we'll see them once they come into the hospital again to give birth. And talk to them once the child is born as well, and we can gauge. Obviously all of these are predictive.

They're not definitive and so it's after the child is born that we see how they're doing, that we kind of give them a little bit more of a definitive plan as to whether we feel like the child's going to need ECMO or whether we feel like when the child can be repaired. And some of the consequences as far as neurologic cardiac long-term pulmonary support. A lot of times we can't necessarily give them that until we are in the midst of taking care of the child.

Interviewer: What options do parents have at this point?

Dr. Fenton: I honestly refer my patients out to websites as well. "I feel like I've given you a lot of information. We want you to know more." There are support groups, CHERUBS is one, as far as the parents can Google. I also had them look at WebMD. I've actually found most parents to be very well informed when they come in even to the prenatal interview. So the very first kind of clinic visit that we have, I found that most parents who come in have already read up quite a bit about it.

Interviewer: Yeah, because they were told about the diagnosis and they're very curious and want to know.

Dr. Fenton: Exactly. And I think that helps. I mean having the parents be informed already about what it is and having specific questions as far as okay, so, tell me about ECMO. Tell me about reflux, and tell me about when you're going to do the repair and what the repair options are. It helps with the conversation already.

Interviewer Do some parents at this point after they get this information choose not to continue the pregnancy if they think... if you think I should say, it's going to be really bad?

Dr. Fenton: Some do. Yeah. I mean some will discuss options of whether to be able to continue the pregnancy or not. Obviously depending on the gestational age of the child, that might not be an option anymore. More often what is talked about is palliative care. So, meaning how aggressive to treat the child afterwards and how much should be pursued.

I would tell you that most parents say, "I want everything done. We'll go forward and certainly want to help the child, after they're born in whatever way is possible." But there are some times where we can't do that. And so I think it's important to have that discussion before, of what are the limits and the possibility of needing to do either palliation immediately after the child is born. And/or when have we exhausted all medical means to help this child.

Interviewer: So, after a diagnosis of CDH, can a child live a normal life after you've done what you needed to do to rehabilitate?

Dr. Fenton: Yes, I think that's the key. We've done what we needed to do rehabilitate or to treat the child, and obviously there is a pretty high mortality associated with CDH now. It has improved greatly over the past two decades. But it's still a serious disorder. There are some kids that have lungs that are so small and so underdeveloped that we're not able to treat those.

Now, the children that we are able to treat, they can go on and live a very productive lives. Some of them may have some challenges secondary to the treatment themselves. They might need oxygen support. They might not be able to exert themselves as much as a consequence of treating their underdeveloped lungs. But most of them can go on and live great lives even if they require some support.

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Interviewer: You're having sinus surgery and you're wondering how you prepare. We're going to talk about those issues next on The Scope.

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Interviewer: The purpose of this podcast is to help you, the patient who's decided that you want to get sinus surgery, to understand what you can do to best prepare for the procedure. There are a lot of things to consider, like how much time do you get off work, do you need to fast before, will you need to arrange for somebody to drive you.
We're going to talk about those and other things right now with Dr. Richard Orlandi. He's one of the experts here in this type of surgery at University of Utah Healthcare. So what's the first consideration that somebody should think about or do before surgery?

Dr. Orlandi: I think the most important thing is they want to be sure about their decision, and I certainly want, in our practice we want to make sure that our patients' questions and concerns are fully addressed before they make this decision. We don't want them to have any second thoughts. And so, again, we try to address every concern that patients have and then certainly encourage them to seek a second opinion.
This is not a surgery, typically, that we have to rush into. Patients have typically had their symptoms for a long time. I think it's something that people can get a second opinion, take their time with this decision, talk to family and others who have had the surgery.

Interviewer: So if they're feeling a little uncomfortable with it or whatever that's a good indication maybe you should ask more questions beforehand.

Dr. Orlandi: Absolutely.

Interviewer: And the sooner the better, of course, because you don't lose your surgery day.

Dr. Orlandi: Well, asking those questions an hour before the surgery may be waiting a little bit too long.

Interviewer: Gotcha. What should I do leading up to surgery day and when does that all start?

Dr. Orlandi: We want the patients to have as much of the inflammation under control as possible, so we ask our patients to continue with the medications that they've been on before. We may stop them for a few days ahead of time for various reasons, but really, we think that continuing that medication ahead of time is really important to control the inflammation.
One of the other things that's really important for us and for our patients is to know what to expect after surgery, so we go through a lot of their post-operative care, actually, before the surgery to make sure they know how to rinse their nose out with salt water, take their medications, and make sure that, actually, even their medication prescriptions that they're going to need after surgery, we try to get those filled ahead of surgery so it's one less thing for them to worry about on the day of the surgery.

Interviewer: We've got a podcast, actually, that covers what to do and what you need to be aware about after surgery, so if you have any of those types of questions, not only check the information that you receive, but you could check out that podcast as well.
So are there any other considerations? It sounds like business as usual, take those medications. How far are you starting out in prep, a week before?

Dr. Orlandi: No, I think that again we're starting about a couple of weeks where we're continuing the medical therapy and then we may fine tune it within a few days prior to the surgery. But it is very similar to other surgeries where you're going to want to follow the instructions that you've been given as far as stopping eating or drinking, usually it's around midnight, sometimes a little later if your surgery is in the afternoon. Making sure someone can drive you. This is a surgery that's done typically under general anesthesia, meaning you're completely asleep. It can be done under local anesthesia if patients prefer. The vast majority prefer to be asleep, understandably.

Interviewer: Absolutely. That's a good consideration. You're going to have to have somebody to drive you home. How many days off of work should you take?

Dr. Orlandi: For sinus surgery, people typically take about a week, sometimes less, sometimes more, but on average about a week. Now if someone is having their septum corrected, the septum is the wall that runs down between the left and the right side of the nose, that septum, it's called a septoplasty to fix that. That septoplasty can actually be a little bit more painful. You're basically talking about kind of breaking the inside of the nose. Now, patients won't be black and blue after that on the outside, but it does cause a little bit more pain and sometimes patients will kind of lean more towards a 10-day time off work after that.

Interviewer: When I'm going in for my day of surgery I'm going to have somebody drive me. Hopefully I've already gotten my prescriptions. Do I need an overnight bag?

Dr. Orlandi: Nope, this is a surgery that's called an outpatient surgery. You come in and go home the same day. Sometimes patients will need to spend the night if they have another condition like sleep apnea or something like that, and that's discussed with the anesthesiologist, but most often this is something that's done in and out the same day, and when the patients do have to spend the night we make those plans ahead of time and so they know that.

Interviewer: For that person that's going to pick me up, can they just wait? Is it that quick of a procedure or should they go do something else?

Dr. Orlandi: It actually depends. There are four sinuses on either side and your surgeon may chose to operate on only one or all eight, so it really depends on the extent of the procedure. This is not a life-threatening surgery so people don't have to wait in vigil in the family waiting room. If they want to go and do something else, we'll call them ahead of time to come pick you up. That's certainly fine, too.

Interviewer: So it sounds like a question to ask and just something to be aware of.

Dr. Orlandi: Absolutely.

Interviewer: What other things do you tell your patients when it comes to preparing for the surgery?

Dr. Orlandi: You know, I think we've covered it. I think again that the most important point is to make sure you're comfortable with your decision. Don't feel rushed into this. This is something that you can take your time deciding on.

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