current sleep apena guidleines

B

BrentB

New member
Anyone know if these are the latest guidelines?

Guidelines Issued on Diagnosing Obstructive Sleep Apnea

The American Academy of Sleep Medicine has issued guidelines on diagnosing obstructive sleep apnea (OSA) in adults.

Among the recommendations with a "strong" rating, published in the Journal of Clinical Sleep Medicine:

•Polysomnography or home testing with a "technically adequate device" should be used for diagnosis in uncomplicated adults with symptoms suggesting an increased risk for moderate-to-severe OSA (e.g., excessive daytime sleepiness plus two or more of the following: frequent loud snoring, witnessed apnea or gasping or choking, or hypertension). For home testing, at least 4 hours of oximetry and flow data should be obtained.


•If home testing yields negative or inconclusive results, or is not technically adequate, polysomnography should be used.


•Polysomnography is preferred over home testing for patients with severe cardiorespiratory disease, possible respiratory muscle weakness, hypoventilation while awake, potential sleep-related hypoventilation, chronic opioid use, or history of stroke or severe insomnia.


•Clinical tools, questionnaires, or prediction algorithms shouldn't be used without polysomnography or home testing.
 
Brent-

Harvey / Hardee is a recently retired professional Polysomnographic Technologist in this field. He will be able to give us the bottom line on this. :wink

Joe. :teeth :thup
 
Brent, as Joe said, I am (somewhat) recently retired so I have not been reading the sleep journals, spending hours in front of a monitor looking at other peoples sleep, and have actually been getting some sleep for myself pretty regularly lately 8)

All of those items listed seem to be appropriate, with the exception of "For home testing, at least 4 hours of oximetry and flow data should be obtained."

When we were do or recieveing HST's (Home Sleep Tests) we would not accept anything less than 6 hours. Now they may have that (4 hour) in there guidelines, but my doc insisted on 6 hours to represent closer to a full nights sleep. Yes, OSA, (Obstructive Sleep Apnea) can be diagnosed in less than 6 hours, But we were always interested in what and what else might be going on as well. (There are also over 105 official Sleep Disorders, so many things can affect our sleep, health and lives.)

Home testing is accepted for treatment perscripting as long as it meets the guidelines but many times, there are other factors involved and a sleep center study is required.
"...(HST)...should be used for diagnosis in uncomplicated adults with symptoms suggesting an increased risk for moderate-to-severe OSA (e.g., excessive daytime sleepiness plus two or more of the following: frequent loud snoring, witnessed apnea or gasping or choking, or hypertension).... Polysomnography is preferred over home testing for patients with severe cardiorespiratory disease, possible respiratory muscle weakness, hypoventilation while awake, potential sleep-related hypoventilation, chronic opioid use, or history of stroke or severe insomnia.


Medicare does pay for 80% (of the allowed), of a monitored polysomnography study (at least that was the program a year ago, and I believe it is still followed) and most secondary insurances will cover the other 20%.Medicare also has some requirements that will provide for followup with your sleep doctor and ensure that treatment is effective.

The advantages of a monitored study is that if anything comes off, (there are about 26 sensors used), they can be replaced to continue the study with appropriate data being recorded. In some places, a monitored stud can be converted from a diagnostic, to a therapeutic evaluation study after there is incontrovertible evidence of severe OSA, saving the patient another night at the sleep center, and in some cases a few $$$.

There are several types of sleep apnea, so not all "stops breathing at night" is OSA, and if that is the case then there may need to be a monitored polysomnogram as a followup to an HST for some patients.

Treatment for OSA is most commonly and most effectively don with a CPAP (Continuous Positive Airway Pressure) device. That is only effective with a properly fitted, and effective interface, (most often called a "mask"). There are tons available and several that will fit, so no "well this will do" stuff here. Perfect fit, or no fit... No in-between.

Hope that is some help. I'm glad to answer general questions here. PM me for personal specifics.

And for full disclosure, I am a retired RPSGT and RT. AND I have been using CPAP for about 8 years now. It makes a world of difference.

Harvey
SleepyC :moon

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Just wondering why one wouldn't just go in to their medical provider to do the testing? My wife convinced me to go soon after we were married. The sleep study involved being hooked up to all kinds of wires, then spending the night in my clinic's sleep facility. Glad I did. Long story short, I was prescribed C-Pap and have slept much better ever since. At the time I was an active airline pilot, and while a few hoops had to be jumped thru, it was not that big of a deal. Now days as a (substitute) bus driver, I also need to show compliance during my physical's for my DOT med card. Again, no big deal. Just a checkup/review with my doctor. Colby
 
I now use a custom fitted mouth guard that holds my lower jaw forward. My friend is a dentist, hence how I got the mouth guard.

There is also another device which sucks onto your tongue and keeps it from falling back in your throat. While more comfortable on the jaw I liked the mouth guard better - but its a matter of preference. For me both worked. https://snoringhq.com/mouthpiece-review ... d-vs-cpap/

I truly dislike CPAP machines due to the Darth Vader noises and the positive air pressure that can wake you up in a panic in the middle of the night. (To be fair it was a unit I used 17 years ago - I am sure they have improved.)

For me the mouth guard is easier to live with and is a heck of a lot more portable.

H
 
For me the problem was not with snoring. I have heard the same comments about older C-Pap machines. That does not appear to be the case any more. My wife right next to me can not hear my machine running. It does provide positive pressure. That is basically the prescription. My sleep apnea involved the stoppage of breathing many times a night. I guess I question how one can sleep with something in their mouth. I suppose no different than having something on your face or nose. My biggest gripe is the hose...but it's rarely a problem. Just sharing info... Colby
 
Brent,

The Aetna article you linked to is pretty old as the Review History box indicates.

Last Review: 03/08/2017
Effective: 08/10/1995
Next Review: 01/11/2018

The article was written in 1995, and though it was review in 2017, I can’t say it meets the AASM guidelines currently. (AASM = American Academy of Sleep Medicine) which is the organization anyone prescribing, reading or diagnosing a sleep disorder should have accreditation with. They should be either an MD, DO, or PhD.

Insurance requirements change at the hint of a nat sneeze, so it would be VERY PRUDENT, to check with your insurance company to be sure you have sleep benefits coverage, and find out what it covers, (what type of testing - in hospital or home, treatment, followup, etc). I have dealt with some who would cover the testing, but not the treatment, or with a diagnostic study but not a treatment evaluation (titration) study. From my point of view that is pretty bad coverage, but then they are into saving money, not caring for your health. For medicare participants, MC has a very strict protocol regarding the followup, and if those steps are not met, they will deny paying for the equipment.

For the most part, the linked site seems current. Right up front in Section B they give their list of “Comorbid” Sleep disorders (PLM, Parasomnia, narcolepsy, or CSA) and I think they are using the wrong term there, as those or not comorbid, but coinsidal disorders. The Comorbid diseases are hypertension, congestive heart failure, atrial fib, stroke, and diabetes. Those are the diseases that will result from untreated Obstructive Sleep Apnea and either obesity or genetic propensity may precurse to result in OSA.

Their treatment appears precise (except as noted above) and is probably close to what they are doing now. For someone with Aetna insurance, going with their policy will probably give you a very good chance of attaining good results. It behooves the patient to be diligent and well versed in their own care. It appears that you are working your way to that.

Best in your efforts.

Harvey
SleepyC:moon

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colbysmith":3e2blg4l said:
Just wondering why one wouldn't just go in to their medical provider to do the testing? My wife convinced me to go soon after we were married. The sleep study involved being hooked up to all kinds of wires, then spending the night in my clinic's sleep facility. Glad I did. Long story short, I was prescribed C-Pap and have slept much better ever since. At the time I was an active airline pilot, and while a few hoops had to be jumped thru, it was not that big of a deal. Now days as a (substitute) bus driver, I also need to show compliance during my physical's for my DOT med card. Again, no big deal. Just a checkup/review with my doctor. Colby
Click to expand...

For most folks, their primary care provider would be a Family Practice physician, (MD or DO) or an ARNP, a nurse practitioner. The standard practice is for them to refer to a Sleep Specialist, which may also be Neurologist, a Pulmonologist, or an Otolaryngologist (ENT - Ear, Nose and Throat surgeon) and Medicare will require follow up with a Sleep Specialist, because they have the training in reading the studies, diagnosing the disorders and prescribing the proper therapy devices. The CPAP (and there are multiple makes and multiple types of devices) that are used for the various breathing disorders that can occur in sleep, are procured from either a DME (Durable Medical Equipment) company which will assist in the medicare required followup, or you can order the device from an equipment provider on line. (I used to tease my patients with asking if they liked their UPS man enough to have him fit the mask?)

The most important part of the equation is the interface, (mask device), that fits between you and the machine. If it does not fit perfectly, there will be leaks or sores, or both, and in those cases, most folks will just give up on using the therapy device. That equals no fix for the OSA, and a bunch of time and money wasted. So it is really imperative to have a well fitting device, whether it is fit by the sleep center that does the testing, the DME company that supplies the machine, or the RT (Respiratory Therapist) that comes in after there are fitting and use issues reported to the Sleep Specialist.

Lots of ways to skin the cat, but the ultimate goal is to obtain a good healthy nights sleep.

Harvey
SleepyC:moon

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Ordutch1975":27tjx6sh said:
I now use a custom fitted mouth guard that holds my lower jaw forward. My friend is a dentist, hence how I got the mouth guard.

There is also another device which sucks onto your tongue and keeps it from falling back in your throat. While more comfortable on the jaw I liked the mouth guard better - but its a matter of preference. For me both worked. https://snoringhq.com/mouthpiece-review ... d-vs-cpap/

I truly dislike CPAP machines due to the Darth Vader noises and the positive air pressure that can wake you up in a panic in the middle of the night. (To be fair it was a unit I used 17 years ago - I am sure they have improved.)

For me the mouth guard is easier to live with and is a heck of a lot more portable.

H
Click to expand...

Ordutch,

Yes there are tons of oral (and tons of other) devices out there on the market. When I was running the sleep center we did testing for several dentists who built devices for treatment of OSA. Yes they are more portable and yes, some of them worked. If you are using an oral device, it would be prudent to have a study done when using the device to be sure it is truly eliminating the affects of the OSA.

We tested one patient who had been wearing an oral device for 15 years, and had recently had a heart attack. His cardiologist told him he probably had sleep apnea. "Well, yes I do, and have been treating it for 15 years, " he told the MD. So the cardiologist said he wanted him in for testing anyway, AND though he had worn the oral device and had had it remodeled several times over time, when we tested, he still had sleep apnea with an AHI (Apnea Hypopnea Index) of over 40. ( 40+ times and hour he was having apnea episodes.) AND during the day, he was still taking 2 naps, plus falling asleep on occasion. After we convinced him to try a new machine and mask he was convinced enough to go the CPAP route claiming he was a new man.

I'm not saying that oral appliances are not effective, just that if someone chooses to go that route, they should be sure to confirm the efficacy.

Surgery is another option, although from my experience it is often less than 100% effective.

Harvey
SleepyC :moon
 
My wife was diagnosed with OSA and underwent several tests including overnight
monitoring which recorded her breathing and blood oxygen saturation. She was
classified as minimum to moderate severity and was headed for CPAP therapy.

Whoa! Some old knowledge of upper airway management said "Not so fast".
She was then fitted for an anterior mandibular repositioning splint by her dentist
which has helped relieve her OSA w/o CPAP or other treatment which can be seen
below. Despite high effectiveness, her "dental" treatment of a medical condition
was not covered by insurance.

"Various methods are used to alleviate snoring and/or OSA. They include behavior modification, sleep positioning, Continuous Positive Airway Pressure (CPAP), jaw adjustment techniques, Uvulopalatopharyngoplasty (UPPP), and Laser Assisted Uvula Palatoplasty (LAUP)."
Click to expand...

And then, if the above does not appeal to you who snore, lose weight.

Aye.
 
BrentB":1shv9z9h said:
Thanks

What questions should I ask staff and facility? Are they regulated and certified?
Click to expand...

IF they are accredited with the AASM ( American Academy of Sleep Medicine ) they YES they are regulated and certified. AND if they are accepting Medicare patients, they are dealing with the largest paying group and most insurances will follow Medicare Guidelines for payment (which will pay 80% of their "allowable" which is not 80% of what the hospital or sleep center may bill. It would be prudent to go to the billing office and clarify the charges that will become your responsibility before the date of the study.

As the sleep testing staff, what time you will need to be there, and what to bring with you, what time you will be up and leaving? Will you need to bring shampoo and towel, will you have a shower available, and if you have medications to take what is their policy?

You may want to ask to see the AASM accreditation certificate. It should be prominently displayed. One of the requirements for Sleep Center accreditation is that there is adequate signage so you can find the center by name from the street to the bed.

Harvey
SleepyC :moon

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My gripe with the local medical "AASM OSA specialist" was there was no
consideration or even discussion of more conservative therapy (bite splint) only
CPAP as "the standard" therapy.

My take away, always ask questions, get other opinions, look around, educate
yourself.

Aye.
 
CPAP is the Gold Standard of Therapy, meaning it is, (can be) 100% effective. There are other therapies, but they usually only work in the more mild cases. Our MD was open to other therapies IF they worked and we did many studies on folks that had any number of "Bite Blocks" and some even tried special "CPAP" pillows.

The most effective oral appliance was the TAP series of dental devices, (which are up to about Series 3 by now). In some cases the dentist would send them in to us to "titrate" the adjustment.

Personally, my sleep study showed my AHI was 28, with oxygen levels going down into the 70's and the longest apneas were just over a minute long. I would wake every morning with a severe headache. One 3 hour nap "test" and waking up without a headache made me a believer. I have tested several thousand patients, and have seen much worse cases of OSA. AND I have seen many more than I could count excellent results. I have also seen folk come in, test and show severe OSA, and then refuse to do what it takes to treat it. I have seen some of them come back years later, after being referred by the cardiologist after they have had more severe complications.

Each person is entitled to manage their own health care, make their own decisions and use what they want. It just seems logical that they also would want to do what is effective, knowing they are treating themselves well.

"My take away, always ask questions, get other opinions, look around, educate yourself."
Click to expand...

Always a good idea.

** Read my tag line **

Harvey
SleepyC:moon :moon

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localboy":3dwizpuv said:
I have recently lost 15 lbs and per The Admiral, my snoring has all but disappeared. So...
Click to expand...
So.... often a 10% weight loss would allow a decrease in CPAP pressures, and for some folks, a 15% would be enough to drop their AHI (Apnea Hypopnea Index) and their snoring to within the MCR guideline below the requirement for CPAP ( = an AHI below 5, or only 5 apneic periods per hour) :smile That doesn'n neccesarily mean you get to move back into the bedroom :shock: but according to the medicare folks, your health (less at risk) is not endangered. Technically, that may be so, be we always tried to have our patients at 2.5 or less. AS I said earlier, mine was 28, and with my CPAP is is usually about 0.2. The best part is not waking up with headaches and not getting sleepy in the daytime.

Mark, Good job on the weight control, it isn't easy. Keep it up. Also, sleeping on your side may help in decreasing the snoring.

Harvey
SleepyC :moon

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