Multiple Sclerosis and Sleep Apnea

In 2009, I was diagnosed with Multiple Sclerosis... 

My life has never been the same. As a mother of six, a business owner and a loving wife; this disease has had a tremendous effect on my life.

"Multiple sclerosis is an unpredictable, often disabling disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body." (1) Multiple sclerosis is not very well understood and scientist still do not know what causes MS. 

Patients with MS suffer from a deterioration (demyelination) of the myelin sheath, which surrounds the nerve fibers throughout their nervous system. It is believed to be caused by environmental factors that are not yet known, which affect a person who is predisposed. One thing that is known about multiple sclerosis, is that three times more women get this disease than men. 

When people think of sleep apnea, they generally think of more common comorbidities (diabetes, obesity, heart failure, hypertension, etc). BUT THE VAST MAJORITY OF PEOPLE ARE UNAWARE OF THE RELATIONSHIP BETWEEN SLEEP APNEA & MULTIPLE SCLEROSIS.


A new study performed by the American Academy of sleep medicine indicates that around 1/5 of a patient suffering from multiple sclerosis will also suffer from obstructive sleep apnea. The study also indicates that almost half the patients who suffer from multiple sclerosis are at an elevated risk of suffering obstructive sleep apnea.

Understanding this relationship is very important and could change the way multiple sclerosis is viewed. This is because one of the most common symptoms of multiple sclerosis is debilitating fatigue. Patients, like myself, who suffer from multiple sclerosis will often find themselves exhausted for days on end, regardless of how much sleep we get it.


BUT it is important to understand that fatigue is also a very common symptom of obstructive sleep apnea. Since obstructive sleep apnea greatly reduces the amount of REM sleep a patient is able to get during the night, patients who suffer from sleep apnea will also suffer from debilitating fatigue.

THAT IS WHY it is important that patients suffering from multiple sclerosis, inquire with their physicians who are involved in their treatment about the possibility of them also suffering from obstructive sleep apnea. By tackling the possibly correlated obstructive sleep apnea, one could greatly reduce the debilitating effects of multiple sclerosis

-Miss Sleep

References

(1). National multiple sclerosis society. "What is MS?" http://www.nationalmssociety.org/What-is-MS


(2). Sleep apnea.com "The link between Sleep Apnea and MS." https://www.sleepapnea.com/blog/ post/88621749594/the-link-between-sleep-apnea-and-ms-by-gina

Answers To Frequetly Asked Questions By Physicians about HOME SLEEP TESTING

How will Home Sleep Testing help my practice?

Home Sleep Testing has been around for many many years and is now being utilized by many in as the primary tool for diagnosing Sleep Apnea. This is partly because Home Sleep Studies are shown to be around 1/2 to 1/4 the cost of the cumbersome In-Lab Overnight Sleep Study. Many insurance companies now require a HST as a first line diagnostic tool. "With proper screening, up to 75% of patients suspected of having moderate to severe Sleep Apnea will only need to have a HST performed to get their diagnosis, making an in-lab study unnecessarily expensive. (1)

In spite of this, it surprising how many doctors still do their best to refer patients to overnight sleep facilities in almost every case they see. I thought that it would be beneficial for everyone to provide some answers to some of the common questions that physicians ask about Home Sleep Testing...... 

Enjoy :)

Answers to Physicians' FAQs about Home Sleep

Healthier patients, better acceptance: Home Sleep Testing (HST) is typically preferred by patients over in-lab studies. They appreciate being able to sleep in their own bed with no one watching them. Patients also appreciate the convenience of an HST. There are no long drives to a sleep lab, and no waiting for an opening to make an appointment. Cost is also a very big concern for patients, particularly those with high co-pays and deductibles. The full cost of an IDS HST is typically less than the co-pay of a lab visit. See the patient section of this website for more benefits to patients. 

More revenue and better relationships per patient: Medicare requires at least two office visits for all Obstructive Sleep Apnea (OSA) patients now: one prior to testing (HST or PSG in a lab) to confirm the patient is a candidate; and a second follow-up between the 31st and 91st day of PAP treatment to determine if the patient is showing clinical improvement. In a sleep lab situation, these visits are typically handled by the sleep physician; while primary care physicians (PCP) prefer to keep their patients in their office. Therefore, IDS provides the PCP with easy-to-read test reports and simpler treatment and titration when utilizing today's auto-titrating PAP equipment with their built-in compliance and efficacy reporting. There may even be additional CPAP initiation codes that can be billed depending on the situation (speak with your CPAP supplier for more information) and insurer. These extra office visits are great opportunities for the PCP to learn more about their patient and strengthen their doctor-patient relationship.

Test results interpreted by a board certified sleep physician: Our panel of board certified sleep physicians reviews and interprets each study and makes treatment recommendations.

Faster results: Many hospital-based and independent sleep labs require a consult with the sleep physician prior to testing. They also have a limited number of beds, making appointment scheduling a long, drawn-out process. IDS not only allows PCPs to refer directly, but provides results in as few as 5 days, and typically less than 10, from the date the PCP orders the test. Patients will likely be treated, on therapy, and getting relief in a week, rather than months later as in many sleep lab programs.

Less hassle: The IDS HST referral form and process is extremely simple. IDS handles insurance verification when needed, allowing the PCP's staff to save time by not having to get approval for a specialist referral.

How reliable is HST technology?

HST technology has been around for more than two decades. It has effectively lowered healthcare costs in Australia, Europe and Canada. Within the past five years, improvements to the technology have made it even more reliable. HST devices now include faster sampling rates on the oximetry channels (better correlation between channels) and simpler setup procedures for patient self-application.

It's difficult to do direct comparisons between the sleep lab and the home because of individual differences from night to night. However, HST is probably slightly less reliable for patients with a borderline Apnea Hypopnea Index (AHI) because sleep time is not measured. That is why Medicare and other insurers have said that it cannot be used as a screener; HST should only be used to confirm sleep apnea in patients with clinical symptoms.

For peer-reviewed articles supporting HST and the historical perspective, refer to the section titled Clinical Evidence. 

Who is a candidate for HST?

HST is intended for patients who exhibit clinical symptoms of Obstructive Sleep Apnea (OSA). Patients with other sleep disorders (i.e. Restless Leg Syndrome (RLS), narcolepsy, REM-behavior disorder), co-morbid conditions (which may impact the diagnostic relevance of the SaO2 data such as COPD or CHF), and patients in whom you only mildly suspect sleep apnea ARE NOT candidates for HST. Patients with hypertension or diabetes ARE candidates, as are those that exhibit symptoms of insomnia. In fact, middle-aged women with OSA may present as sleep maintenance insomniacs—their OSA could be made worse with hypnotics (Reference: Shepertycky et al.). Signs to watch for include:

• Loud snoring
• Witnessed apnea events
• Excessive daytime sleepiness
• Morning headaches
• History of high blood pressure
• Memory problems or poor judgment
• Depression
• Gastroesophageal reflux
• Impotence
• Nocturia
• Difficulty concentrating
• Personality changes or irritability

How do I perform the clinical assessment?

First, you will uncover patients at risk for OSA in one of two ways. They are:

• Ask the patient to complete the Epworth Sleepiness Scale.
• Ask the patient the Five Simple Questions for OSA Screening which include:
  • Do you snore?
  • Are you excessively tired during the day?
  • Have you been told you stop breathing during sleep?
  • Do you have hypertension?
  • Is your neck size greater than 17 inches (male) or 16 inches (female)?

If your patient answers "yes" to at least two questions he is a candidate for HST.

Finally, do a cardiopulmonary assessment to rule out exclusionary disorders such as COPD and CHF. Examine the upper respiratory airway looking for enlarged tonsils, obvious asymmetries or blockage of the nasal passages and document your findings in the patient’s chart.

How fast can I get the report?

IDS typically contacts the patient and ships a device the same day the order is received. We process the data and provide an interpretation within a matter of hours of it being returned by the patient. Typical turnaround time is 7-10 days from the physician's order to test results.

What is the cost to the patient?

That depends on the patient's insurance. For example, the cost for a patient with Medicare and no supplemental insurance is $30.25 (depending on Medicare allowable). The cost will never be more than $250, even for those without insurance. To put it in perspective, an HST is between one-fifth to one-tenth the cost of an in-lab sleep study.

What data will I get?

IDS uses the ResMed ApneaLink Plus Type III device which records four channels from two sensors. A nasal pressure cannula records airflow and snoring, while a finger sensor records oxygen saturation and heart rate. The Type III ApnaeaLink device also records respiratory effort. See the section titled Sample Test Report for more specific examples.

Will my older patients be able to follow instructions? 

IDS provides an instructional DVD that illustrates how to apply the device and very detailed printed instructions which have been developed based on our success in home overnight oximetry testing. The instructional brochure contains professionally drawn illustrations developed just for IDS patients who may have trouble reading the instructions. The illustrations include diagrams showing them applying the nasal cannula, sliding on the finger sensor, confirming the device is working and packing equipment back in the envelope. We also provide a toll-free, support line that is available 24/7. IDS Patient Support is staffed by qualified sleep technicians for patients who still have questions or experience difficulties. Our success rate of 98% easily exceeds published industry standards.

Can I do follow-up studies? 

Medicare, and possibly other insurers, will only allow the new HST code to be billed once per year. However, an overnight oximetry test can be performed to determine whether or not a patient still has oxygen desaturations while on CPAP.

A DME in my area is doing the testing themselves. Can they do that?

For Aetna, Humana and private pay patients, they can. However, Medicare excludes a company or its affiliate from diagnosing and treating a patient. Unlike oximetry testing in which the DME can deliver the device and act as a "courier of equipment". The DME is not to be involved in HST in any way according to CMS rules.

IDS is the only company that, as an independent diagnostic testing facility (IDTF) without any co-ownership ventures with DMEs, can test patients with any insurance, in any state without risk of penalties.

Another company is including the clinical evaluation as part of their HST service. Isn't that a better option?

Medicare has made it clear that both the evaluation and the follow-up visits must be done by the treating physician (there are allowances for nurse practitioners under the treating physicians to be involved). These services are fine for private pay patients or insurers whose policies differ from Medicare's, but it's difficult to track of which policies approve and which policies disapprove.

The intent of IDS Sleep is to help PCPs become more comfortable talking with their patients about their sleeping habits. Treating sleep apnea has been shown to improve glucose control in diabetics, lower blood pressure, reduce the risk of heart disease and stroke and increase energy, allowing patients to exercise and lose weight. With discussions at the nation's capital focusing on pay-for-performance and the medical-centered home, we believe this approach benefits patients and makes PCPs more likely to succeed should such changes be implemented.

What's going to happen to the sleep labs? My hospital just spent a lot of money to build one.

HST is for uncovering sleep apnea specifically. We anticipate that as physicians begin asking questions about sleep, other issues which require a comprehensive evaluation in a sleep lab will be uncovered.

Where can I find guidelines for administering Auto-Titrating Positive Airway Pressure (APAP) treatment following a positive test and clinical evaluation?

The AASM (American Academy of Sleep Medicine) provides practice parameters on their website.(2)

-Miss Sleep

REFERENCES

(1). (Sep, 2013). K. Philips. Home Sleep Tests V.S. In Lab Tests; Which is Best? Alaska Sleep Education Center. Retrieved from: http://www.alaskasleep.com/blog/home-sleep-tests-vs-inlabsleep--tests

(2) (June, 2008). Instant Diagnostic Systems. "Frequetly Asked Questions By Physicians" Retrieved from: https://www.instantdiagnostic.com/ids/(S(cinbyq2bvejyljiyo4gw24bp))/ content.aspx?content=Physician_Home_Sleep_Testing_FAQ

Welcome to the RE-LAUNCH of my SLEEP HEALTH BLOG! :)

As a Registered Sleep Technician and a Respiratory Therapist; building awareness about Sleep Medicine has always been a major passion of mine. Through this blog, my aim was to help spread awareness about Sleep Apnea and all other important aspects of Sleep Health. 

A number of years ago I was diagnosed with Multiple Sclerosis. All of the various care I have been undergoing, combined with my family and my sleep therapy business, left me with little time to contribute to this blog. 

BUT.... Now I am back! I have decided that building awareness about the dangers of unhealthy sleep is too important. I am fortunate enough to be in a position to spread my knowledge of this vitally important topic; to those who do not have my clinical background.

So I welcome you to follow my blog as I will be sharing educational material, my own personal experience/opinions and anything else that I think will help people become more aware of the importance of sleep health. If I can even just make one person's life better though my blog, then it will be more than worth my efforts.... :) 

Sincerely...

Miss Sleep

A Grande Starbuck's coffee has FOUR TIMES MORE CAFFEINE than a Redbull!

Many people like to boast that "that they do not drink energy drinks, cause they just don't like all that caffeine." But millions of Americans love to start the morning with a visit to Starbucks. But what many people do know is that Starbucks coffee contains a disproportionally large dose of caffeine, when compared to other caffeinated drinks. HERE ARE A COUPLE SURPRISING FACTS:

A Grande 16oz Coffee from Starbucks contains FOUR TIMES MORE CAFFEINE than an 8.4oz Redbull  

                                             330mg         VS          80mg

A Grande 16oz  Coffee from Starbucks contains almost 2.5 TIMES MORE CAFFEINE than an 16oz McDonald's Coffee.   

                                                  330mg        VS       133mg


Even though a morning jolt can make the mornings easier to deal with, it is important that people are aware of the potential effects of drinking TOO MUCH CAFFEINE. Although moderate caffeine consumption isn't likely to cause harm, drinking more than 500mg can cause:

Insomnia

Nervousness

Irritability

Fast Heartbeat

Upset Stomach 

Muscle Tremors

At 260mg of Caffeine, it would only take two tall 12oz coffees from Starbucks to put you over 500mg!

-Mr. Sleep

References:

Mayo Clinic Online, (March, 2011). "Caffeince: How much is too much?" 1998-2013. Mayo Foundaition for Medical Education and Research. 

                 

Center for Science in the Public Interest. (2013). "Caffeine Content of Food and Drugs"

Celebrity Sleep Deaths....

"Isn't that just snoring?" This is what you hear a lot, when you talk about Sleep Apnea. Many people are unaware that Sleep Apnea is a very serious disorder that can kill you (Sudden Cardiac Death). Sleep apnea also causes serious and life-shortening disorders: high blood pressure, heart disease, stroke, automobile accidents caused by falling asleep at the wheel, diabetes, depression and other ailments (ASAA). 

Today I learned that these celebrities all died at the hands of Sleep 

Apnea: 

Jerry Garcia 

(Grateful Deal)

John Candy

(Stripes, Cool Runnings, Space Balls, Etc) 

Reggie White

(Packers, Eagles, Panthers)

Chris Penn

(Reservoir Dogs, Rush Hour, All the Right Moves)

It is important the when building awareness about sleep apnea, you stress how deadly the disorder is. In doing so, hopefully we can prevent further loss of life...

-Mr. Sleep

OOPS! I forgot to wear my CPAP!

Could sleep apnea be responsible for Rick Perry's now infamous OOPS moment during his disastrous republican debate performance?

It turns out that out that Governor and former presidential candidate Rick Perry was diagnosed with sleep apnea while he was campaigning during his failed bid for the republican presidential nomination. A spokesmen for Perry's office confirmed that the Governor had been diagnosed with sleep apnea that had not treated when at the time he famously forgot to recall one of the three federal agencies he had proposed eliminating (in mid debate). The OOPS moment (as it has been dubbed) was considered by most to be the moment that ruined his already troubled bid for president.

The aid who reported that the Governor was suffering from sleep apnea speculated that Governor Perry could have been suffering from the disorder for years before he was diagnosed. Since it has been shown that untreated sleep apnea can cause tissue loss in areas of the brain that help store memory, once can't help but wonder if Perry's presidential bid would have been more successful if he had been wearing his CPAP!

Click here to view the incident (though it is painful to watch) 

-Mr. Sleep

Sleep Apnea Causes Cancer???

As the list of disorders that are associated with Sleep Disordered Breathing (SDB) continues to grow, the latest addition to the list has certainly raised eyebrows. A new study performed at the University of Wisconsin School of Medicine has demonstrated "increased episodes of hypoxia (inadequate supply of oxygen) are associated with accelerated cancer progression." (SleepReviewMag, 2012). The study (although done in vitro and on animals) suggests that sleep apnea increases the cancer mortality rate in humans.

This study is fascinating and will spawn a series of sub-studies that will likely reveal more specific details about this correlation. In the meantime, it is important to spread the word about the relationship between cancer and sleep disordered breathing to family doctors, internists, oncologists and pretty much everyone else...

(Click Here For The Full Article)

-Mr. Sleep

OSA and diseases of the eye

As sleep disordered breathing become better understood, health professionals are becoming more and more aware of how the disorder relates to other diseases. Two new studies have recently been published that show that people with sleep disordered breathing have a higher risk of cancer.

Another relation that is not very well known, is the relation between sleep disordered breathing and diseases of the eye. Dr, Swaraj Bose is a board certified ophthalmologist, a neuro-opthalmologist and an orbital surgeon who specializes in treating patients with diseases of the eye in relation to the brain. On his blog, he recently posted an article that examines the links between sleep disordered breathing and disease of the eye. His article explains that sleep disordered breathing can cause Non Arteritic Ischemic Optic Neuropathy (NAION), Idiopathic Intracranial Hypertension (IIH) / Pseudotumor cerebri (PTC), Floppy Eyelid Syndrome (FES) and Glaucoma / Normal Tension Glaucoma.

To read Dr. Bose's article, click here.

A Sleep Study on the Subway????

A Couple of New York doctors decided to do a sleep study on a New York subway?


Ever wonder if napping on a bus or on a subway ride was even worth the trouble??? Well after seeing New York's subway passengers constantly sleeping (or attempting to sleep) on a subway that is known for screaming and guitar playing passengers, these doctors decided to perform a sleep study to see if they could get into any stage of sleep deeper than stage 1.....Using a homemade quasi-PSG (they jimmy-rigged using an I-Pod) they sought out to see if restorative sleep on the subways of New York was possible.



Click here to read the New York Time's article....

The 10 Most Sleep Deprived Cities

The CDC has recently released a study which identifies the cities that have the highest percentages of sleep deprived people. They are as follow:

1. Detroit
2. Birmingham, Alabama
3. Oklahoma City, Oklahoma
4. New Orleans, Louisiana
5. New York, New York
6. Cincinnati, Ohio
7. Louisville, Kentucky
8. Raleigh, North Carolina
9. Columbus, Ohio
10. Boston, Massachusetts

The rankings are based on individual sleep habits as reported in an annual study by the CDCP of more than 350,000 adults in all 50 states. The findings took into account the percentage of time people don’t get enough sleep or rest, and the percentage of people who say they don’t get enough sleep more than half of the time.

-Mr. Sleep

References:

http://www.sleepdt.com/is-your-city-listed-in-the-top-10-most-sleep-deprived-cities-3/

Swift FX for her

Insurance companies requiring Home Sleep Tests prior to the Sleep Lab!

United Health Care appears to be the leader in the push to bring Home Sleep Testing (HST) to the forefront of diagnostic sleep medicine. As of October 1st, all UnitedHealthcareWEST, Neighborhood Health Partnership and River Vally members will be required to have a pre-authorization for all sleep studies. If a provider attempts to perform an in-lab study on a patient who meets United's criteria for a Home Sleep Test, their pre-authorization will be denied. This denial will in turn leave HST as their only available option to diagnose the patient's sleep disordered breathing. United's new policy will also require patients to undergo at-home titrations using Auto-Titrating CPAP devices, in the place of in-lab titrations when appropriate. (click here to read United's Official Policy).

Last month Premera Blue Cross (a Blue Cross licensee out of Washington) announced its plans to mimic United's approach to diagnostic sleep medicine. These changes were announced just one month prior to when United's policy was to become effective (click here to read the Premere Blue Cross official policy).

Given the fact that cuts in Medicare are likely to occur in the next few years, we can expect to see more and more insurance companies start to accept the HST model. If Medicare decides to start pushing its patients towards the HST model, this would break up the near monopoly of diagnostic sleep medicine that sleep labs have long enjoyed. Instead of being the source for the majority of all sleep diagnostic needs, sleep labs will eventually become the secondary source for diagnosis, relegated to studying patients who do not qualify for HST (cheyne-stokes breathing, neuromuscular disorders, pulmonary issues, etc).

While the HST model will ultimately save the payers money, many feel that its implementation will not be in the best interest of the patient. Individuals with pulmonary issues, cardiac problems and neurological problems (PLM's, RLS, etc) that are undiagnosed, will likely have have to wait longer to receive therapy. Since these disorders are easily identifiable during an in-lab sleep test, patients with these issues currently receive expedient care. This is because overnight tests often detect many other disorders, aside from sleep disordered breathing. Under the HST model these patients will first have to undergo a HST which (depending on the unit used) will likely not pick up any of these disorders. They will then have to return to their physician who will likely have to refer them to an overnight facility where these types of disorders can be observed.
-Mr. Sleep

References

Premera Blue Cross. (2011). Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome and


Upper Airway Resistance Syndromehttps://www.premera.com/stellent/groups/public/documents/me


dicalpolicy/cmi_003508.htm


United Healthcare Online. (2011). July 2011, Network Bulletin. https://www.unitedhealthcareo


nline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tool


s%20and%20Resources/Network%20Bulletin/NetworkBulletin_July2011supplement.pdf

Medications that cause abnormal dreams...

Often times people with sleep disordered breathing state that they do not dream. Since REM sleep is often when SBD is at its worst, patients often cannot ever recall dreaming since they do not experience enough consistent sleep to significantly dream. Once these patients are placed on CPAP and get uninterrupted REM sleep, they often start to call CPAPs "DREAM MACHINES." But often times frequent dreaming can come with its own set of problems. I once had a patient who experienced so many bad dreams that he decided to discontinue CPAP. 

It is important to attempt to understand some of the factors that can cause abnormal dreams. Many people are aware that stress and anxiety can cause bad dreams to occurs. But many people are unaware that many common medications can also alter ones dreams. These drugs include certain antidepressants, antibiotics, beta blockers, blood-pressure medications, cholesterol medications and drugs for Alzheimer's and Parkinson's diseases. Abnormal dreams are most common when an individual first starts or decides to quit taking drugs such as these (Beck, 2011). Although not completely understood, many sleep physicians tend to think that abnormal dreams can occur whenever REM sleep is disrupted. If you or someone you know starts to experience frequent nightmares, it is important to alert your physician.

-Mr. Sleep

Beck, L. (2011). The Next Nightmare. The Wall Street Journal.

The Respironics True Blue Nasal Mask

A New Round of Nasal Masks from both ResMed and Respironics have recently hit market. It is likely not a bad idea to have some knowledge about these new masks, since both organizations are marketing them heavily to sleep labs. The True Blue Nasal Mask is the newest mask from Respironics. 

From a patient's perspective:



The True Blue Mask boasts new technology which Respironics calls the "Free Form Spring". The spring somewhat resembles the adjustable piece on the nozzle of a gas pump, as the spring will push the cushion into sealing and will also adjust the cushion accordingly as the mask frame is pulled to either side. The technology appears to be efficient at keeping the mask from leaking. One can demonstrate this to a patient during a mask fitting by bending the mask frame to either side to simulate how a leak could normally form. The mask will remain sealed despite the mask frame being pulled around 20 degrees to either side. The clips at the front of the mask frame are also extremely convenient. Some masks such at the ResMed Quattro require the patient to push the clip in at a very specific angle, which can be difficult for the elderly or others with dexterity issues. The clips on the True Blue are extremely easy to latch, as one can latch them from almost any angle. Another added feature is the gel cushions that rest on the patients forehead. These three pads cover a large surface area and are extremely soft, making them ideal for patients who have problems with skin irritation from the forehead piece. The one downside to the True Blue is that it is a bit cumbersome when compared to some of the other smaller nasal masks. I think the bet that Respironics is making is that all the new features this mask offers will compensate for it being just a little bit large.

From a clinician's perspective:

I currently have around three patients wearing the True Blue Nasal Mask. They all three have stated that the mask is extremely comfortable and state they have not had any problems with the mask leaking. If a technician takes some time to show them how the Free Form Spring will help prevent leakage, I have noticed that it can cause patients to get excited about the mask. Often times these little features can be used as selling points which get the patients excited and more involved in their therapy. The one issue that clinicians could take with the mask is the fact that the it comes in five different sizes (P,S,M,MW,L). Stocking five different mask sizes along with five different cushion sizes separately can be somewhat of an irritant to clinicians. That being said I do believe that from what I have seen thus far, the mask is truly innovative and is worth stocking. I will report back to you later once I have had more experience with the True Blue.

-Mr. Sleep

Sleep Eating

The woman featured in this video caught herself sleep eating with a video camera. Night time eating syndrome (NES) is characterized by late night binge eating that often times happens without the person's knowledge. NES as with most sleep walking disorders can be caused by high levels of stress and is also thought to be related to Sleep Apnea along with Restless Leg Syndrome. NES is a dangerous condition as sleep eaters usually target foods with high fat/high sugar. Many people who suffer from NES will take steps to prevent it such as locking the refrigerator, using motion detectors and even eating extra large dinners (so they will not be hungry during the night).

The woman featured in this video is literally asleep while she is raiding the refrigerator and almost appears zombie like while binge eating. (click here to view).

No more Medicare referrals for HME providers?!?!?!

Sleep Labs May Soon Be Able To Set Up Their Own Medicare/Medicaid Patients With CPAP Equipment!!!


On September 16th 2011, the AASM presented the final draft of a proposal to create a pilot program that integrates sleep management and HME delivery. The model is basically a test program that will give sleep physicians much more control over their patients sleep therapy. This would include dispensing equipment to Medicare/Medicaid patients, that they themselves diagnosed.

The pilot model will be overseen by both the AASM along with the center for Medicare/Medicaid Innovation. According to Nancy Collop, the president of the AASM, the programs aims at" improving patient care and giving more power to the sleep physician to guide the patient through the process."

Flaherty, 2011. AASM shifts sleep strategy. HME News

Sleep Apnea Screening for Smart Phones

Looks like the Smartphone craze has finally caught up with sleep medicine...An organization called Sleep Group Solutions has launched an app that patients can download that screens them for OSA and then helps them get in contact with clinicians in their area.


The app actually has the ability to send the data from your screening to clinicians in the area, thus saving a potential patient a phone call. To download the app, visit the MSleeptest website...

-Mr. Sleep

Bizkit the Sleep Walking Dog

Bizkit the Sleep Walking Dog

  


Sleepwalking occurs when the sleeper comes out of slow wave sleep in a state of low consciousness and performs activities that are usually performed when the sleeper is fully awake. (1) These activities can be harmless activities such as talking, walking around, and cooking. Sleepwalkers have also been known to perform activities that require high motor function such as driving a car. There have also been about 69 known cases known to date of homicidal somnambulism or sleep murder! (2)

Although in the video Bizkit does not hurt anyone else, he probably woke up surprised and with a sore head. I wonder what he was dreaming about? Enjoy!

-Mr. Sleep

The airport sleep box!!!

A private place to sleep in airports would certainly be better than sleeping on a chair one foot away from a complete stragner, wouldn't it? Well it looks like Russia might be the first country to capitalize on these sleep deprived individuals who have no place comfortable to rest during a layover. May I present, THE SLEEP BOX!!!






The video is pretty self explanatory and I think that all airports should invest in these boxes (for my own sake). I do not know about you but I've never been particularly fond of sleeping in airports.

Oh and if I were a CPAP vendor, I would take note of this post. I'm sure some patients might need a CPAP equipped sleep box!

-Mr. Sleep

Wanna save on your kids college tuition!

Then make sure they sleep 9 hours a night.....

A new study undertaken shows that if your children sleep less than 9 hours per night, than they are likely to learn at a less than optimal level! This could mean less scholarships and more tuition!

Click the link below to read the full article: http://www.sleepreviewmag.com/sleep_report/2011-09-21_01.asp

-Mr. Sleep

Why thank you so much sir!

Taking good care of your patients really pays off, especially when they bring you an unpretentious little red to enjoy after work....

The Mirage FX

A New Round of Nasal Masks from both ResMed and Respironics have recently hit the market. It is likely not a bad idea to have some knowledge about these new masks, since both organizations are marketing them heavily to sleep labs. The Mirage FX is the newest nasal mask from ResMed, an organization which was co-founded by Colin Sullivan (the man who published the first paper on Obstructive Sleep Apnea).

 
From a patient's perspective:

The Mirage FX is a compact mask that is designed to be simple, comfortable and lightweight. I have only fit one patient with the mask so far but when I did he stated that the mask was much more comfortable than his previous one. ResMed boasts that the Mirage FX is simple to assemble, as it is composed of only three different components (not including headgear). As the mask is indeed simple to assemble, this makes it optimal for patients who have issues with dexterity. It also has a quick release snap above where the tubing connects to the mask for patient convenience, as some patients can have trouble disconnecting the tubing.

 

 

From a clinician's perspective:

The Mirage FX's standard pricing is around $100 dollars although HME's can likely get better pricing if they order it with ResMed machines. While this is a little on the expensive side, it does appear to be a high quality mask that will likely result in patient satisfaction. ResMed also boasts that the Mirage FX makes reciprocal supply distribution easy for providers. Instead of having to stock a variety of different sizes in bulk (shallow wide, small shallow, etc) the Mirage FX is backed by studies that show that 90% of people will fit its medium (or standard) size cushion. This would make both fitting and stocking the mask and its cushions less complicated for clinicians.

 

I only have one patient on the mask and have not yet had enough clinical experience with it to speak to its quality with any certainty. But the mask does appear promising.....I will post again when I know more.

 

-Mr. Sleep

Sexsomnia???

While almost everybody knows about the more common sleep disorders (such as sleep walking or sleep talking), most are unaware that there are much more bizarre things that can occur while you are sleeping, without your knowledge. People with NREM disorders (such as sleep walking) can in some cases have higher exhibit high motor functions in their sleep. Individuals have been documented walking, talking and even driving during sleep. But in a more unusual case, in 2004 a woman in Texas had sex with FIFTEEN complete strangers, ALL WHILE SLEEPWALKING AND WITHOUT HER KNOWLEDGE! (click here to read).


Sleep sex (or sexsomnia) is a NREM parasomnia in which people engage in various sexual acts, while they are still asleep. In many cases, individuals who suffer from sexsomnia, can commit acts that would be considered sexual assault if they had been commited consciously. Below is a clip I found that sums up the disorder pretty well.



I love how the above video noted that men were found engage in sleep sex more than women......Why does that not surprise me?

-Mr. Sleep

References:

"Sleepwalking woman had sex with strangers". New Scientist. 15 October 2004. http://www.newscientist.com/article.ns?id=dn6540

ONLY AFTER ONE MONTH!!!!

After just one month a transfer patient (from where I will not say) was able to produce what is likely the dirtiest filter I've ever encountered. Even though at each initial setup I make a point to remind the patient (multiple times) to check the filter once a week, I also still have patients who come in with filters that are beyond dirty! I just cannot stress how important repetition is when it comes to educating individuals about sleep therapy.

-Mr. Sleep 

An alternative to CPAP or another wannabe?

          Legend has it that it all started one night when an Australian professor, physician, and soon to be inventor was watching his friends bulldog sleep. As Colin Sullivan MD sat there and watched his friends bulldog choke and gasp for air, he suddenly realized that higher air pressure could keep the dog's airway open! By 1980 Colin had invented the first ever CPAP (Continuous Positive Airway Pressure) device. Although the first machines were loud and the masks were crude; they were effective. Ever since CPAP has became the dominate clinical solution to treating sleep apnea.
                                                                             UPPP

         
                                                           A patients airway after surgery
  
          But although CPAP remains the dominate solution, there have been many different approaches to treating OSA that have sought to overtake or replace CPAP. There is the Uvulopalatopharyngoplasty surgery or UPPP. This surgery removes tissue from the upper airway. As a clinician I can tell you that I have seen many patients undergo this surgery who then return to the sleep clinic who's sleep apnea is unchanged or even worsened in some cases. Although it does work on some, in my opinion the results are not very promising or consistent.

Didgeridoo

          I know at this point your probably thinking that this post is getting a little strange. But a recent study in the British Journal of Medicine has spawned a small movement of patients and entrepreneurs dedicated to using the giant horn featured above to treat sleep apnea.(1) It actually makes sense. Blowing this large horn requires a lot of respiratory drive. This respiratory effort along with the vibrations the horn makes will strengthen the patients upper airway if the horn is played regularly enough. How permanent is this change? Do I need to keep using the horn? What if I have severe OSA? These are all good questions that will likely be unanswered until the device is used rigorously by a large number of patients. Below is a video that explains the process.
         


          The idea of strengthening the airway by exercising it is a very good idea. Instead of just using the CPAP to band aide your apnea, people are actually able to restore their airway back to normal with this form of treatment. But I don't think that this horn will ever REPLACE CPAP. I just can't imagine clinics issuing horns for people to use at home. Most of the places that offer these horns tend to have more of an alternative medicine feel. Can you imagine doctors prescribing giant horns? I can already picture the look on a patient's face when they hear they are about to be given a giant horn. It just does not have a clinical feel and does not really fit into most people image of health care. Also it likely would not fit into many peoples lifestyles. People have families, have to travel, are really busy, and just don't have great environments to play a loud horn in. Although strengthen the muscles in the airway I believe could have a lot of potential for the future of sleep medicine; I do not believe the didgeridoo is the appropriate way of achieving it.

          The newest approach that I have heard is featured above. The Provent nasal valves claim to "reduce" the effects of OSA and are supposedly backed by double blind studies. The way that these plugs work is actually pretty smart. They completely cover each nostril. When the patient breathes in the valves lets them pull air through each valve unrestricted. But then when they breathe out their nose, the valve partially restricts the flow of air flowing out. This builds up pressure in the airway which serves as the famed nasal splint that CPAP also uses to keep the airway open. A patient who uses these plugs would not need a mask, tubing, a machine, etc. (Below is a not-so-impressive video of how the device works).



          But there are a few issues that I have already identified with this type of therapy. First of all is that once you have the nasal plugs in it is very difficult to breathe out through your nose. Provent states that patients wearing Provent at night have to get used to breathing through their mouth while they are falling asleep. This could be uncomfortable for some. This made me wonder "What about mouth breathers who are unable to breathe through their nose? Or those who can brethe through their nose but for whatever reason also breathe their mouth?" Provent reps claim that patients naturally breathe through their nose at night, unless it is blocked. As a sleep technician I have seen hundreds of people who have no nasal blockage who breathe through their mouth at night, even on CPAP. This is not even counting those with deviated septums, chronic congestion problems, skin irritation, chronic nasal bleeding, etc. But like everything Provent is obviously not for every patient. But this does not mean that it does not have its place in sleep medicine.

         The second issue I have with the Provent nasal valve is in its claim to "reduce" the effects of OSA. A reduction of OSA in my opinion should NOT be the desired end result. A complete reduction should be. If a patient's OSA get reduced by half, that patient could still be waking up constantly, they could still be having breathing events that will likely cause health problems down the road, and still possibly be bothering their bed partners with snoring. In my opinion more research needs to be done that specifically states how often it can cure OSA. If this research does exist I would certainly like to see it.

          Although there are issues that need to be worked out I must say that this therapy does have its place. Lets face it, no matter how skilled and persuasive of a clinican or physician you are; there are those who will never adapt to CPAP. These patients could just not care, be unable to adapt, not want to pay their co-payments, and/or believe that CPAP is just a money making scheme. These patients could benefit from Provent. If you cannot cure them with CPAP then reducing their OSA becomes much more attractive. It also can bring in revenue for Providers on patients that would be lost otherwise. People who do not like CPAP also find Provent to be attractive since it is much less cumbersome than CPAP. Also for people that it can cure, perhaps this could be a more desired method of treatment than CPAP.

          Ventus Medical, the organization that created and sells Provent has done a really good job bringing its Product into the market. They have hired a sales force that understands the business and all the different players. They are currently pursuing a HCPC code for their product so that insurances will cover its usage, and most importantly it does not seem like they are not attempting to replace CPAP. They are approaching providers with an alternative to CPAP that providers can attempt to use to treat the percentage of their patients that have failed CPAP. Recently the product was even shown on the hit daytime show The Doctors. It will be interesting to see how the products performs in the market. As always I will keep you posted on my experiences with it.

-Sleep Guy

References

(1). Puhan M et al. Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomized controlled trial. British Medical Journal. 2006. 332:266-270.