HOME OBSTRUCTIVE SLEEP APNEA MANAGEMENT IN THE USA AND ABROAD P. LYNN NICHOLS, M.D. DABSM,FCCP

HOME HOME OBSTRUCTIVE OBSTRUCTIVE SLEEP APNEA SLEEP APNEA

MANAGEMENT IN MANAGEMENT IN THE USA AND THE USA AND

ABROADABROAD

P. LYNN NICHOLS, M.D.P. LYNN NICHOLS, M.D.

DABSM,FCCPDABSM,FCCP

MEDICAL DIRECTORMEDICAL DIRECTOR

Summitsleeptn.com

Financial disclosuresFinancial disclosures

I make a living as a pulmonologist I make a living as a pulmonologist and sleep physicianand sleep physician

No large medical company has ever No large medical company has ever offered me any money, but I am offered me any money, but I am open to the ideaopen to the idea

WHAT IS THE NAME OF THIS PROCEDURE,

ANYWAY? Home Sleep Testing (HST)Home Sleep Testing (HST) Out of Center Sleep Testing (OCST)Out of Center Sleep Testing (OCST) Portable Monitoring (PM)Portable Monitoring (PM) Limited Channel Testing (LCT)Limited Channel Testing (LCT) *proposed- Home Obstructive Sleep *proposed- Home Obstructive Sleep

Apnea Management (HOSAM)Apnea Management (HOSAM)

GOALS

Scientific rationale for HSTScientific rationale for HST HST experience in socialized HST experience in socialized

medicine (New Zealand)medicine (New Zealand) HST four year experience in private HST four year experience in private

US Sleep CenterUS Sleep Center Where is sleep disorder management Where is sleep disorder management

headed in the US?headed in the US?

SCIENTIFIC RATIONALE SCIENTIFIC RATIONALE FOR HST/HOSAMFOR HST/HOSAM

NEW ZEALANDNEW ZEALAND

HAKAHAKA

The Challenge

Design and implement an Design and implement an obstructive sleep apnea diagnostic obstructive sleep apnea diagnostic

and treatment program for and treatment program for 150,000 rural New Zealanders150,000 rural New Zealanders

NZ$100,000 SLEEP NZ$100,000 SLEEP PROGRAMPROGRAM

OTHER RESOURCESOTHER RESOURCES

One respiratory therapist dedicated One respiratory therapist dedicated to pulmonary function lab and sleep to pulmonary function lab and sleep program (I had to hire)program (I had to hire)

4 small hospitals/clinics with nursing 4 small hospitals/clinics with nursing staffstaff

Chartered airplane (my favorite)Chartered airplane (my favorite) Support of Auckland sleep labSupport of Auckland sleep lab

MORNING COMMUTEMORNING COMMUTE

IT’S ALL ABOUT THE IT’S ALL ABOUT THE ALGORITHMALGORITHM

GP referral letter to Respiratory ConsultantGP referral letter to Respiratory Consultant Home sleep test with follow up at next Home sleep test with follow up at next

respiratory clinic with initiation of Auto respiratory clinic with initiation of Auto CPAPCPAP

Auto CPAP download next CPAP clinic and Auto CPAP download next CPAP clinic and placed on cheaper fixed CPAP unitplaced on cheaper fixed CPAP unit

CPAP clinic follow ups with RTCPAP clinic follow ups with RT Referral to Auckland if necessaryReferral to Auckland if necessary

OUTCOME AT ONE YEAROUTCOME AT ONE YEAR

Around 70% of patients could be Around 70% of patients could be managed without in-lab study initiallymanaged without in-lab study initially

Recruited a respiratory consultant Recruited a respiratory consultant from South Africa to continue the from South Africa to continue the programsprograms

Home Sleep TestingHome Sleep Testing

Technical PerspectiveTechnical Perspective

Nicole Line, RPSGT, RST,PSGPNicole Line, RPSGT, RST,PSGP

Clinical DirectorClinical Director

DISCLAIMERDISCLAIMER

The following slides are opinions derived The following slides are opinions derived from our experiences at Summit Sleep from our experiences at Summit Sleep Services and are in no way representative Services and are in no way representative of all Sleep Center situations.of all Sleep Center situations.

As techs, our first reaction to As techs, our first reaction to HST…….HST…….

Embletta Gold by EmblaEmbletta Gold by Embla

Embletta Gold by EmblaEmbletta Gold by Embla

Features:Features: Easy application with color coded sensorsEasy application with color coded sensors Pre-program multiple studiesPre-program multiple studies Rechargeable battery Rechargeable battery Internal position sensorInternal position sensor Ability to record 12 channelsAbility to record 12 channels

Embletta Gold by EmblaEmbletta Gold by Embla

Limitations:Limitations: Heavier unitHeavier unit Difficult for patients to apply Difficult for patients to apply

themselvesthemselves Somewhat difficult to scoreSomewhat difficult to score

Nihon Kohden NomadNihon Kohden Nomad

Nihon Kohden NomadNihon Kohden Nomad

Features:Features: Integrates with NK systemIntegrates with NK system Auto starts with pulse signal or can be set Auto starts with pulse signal or can be set

to start at a designated timeto start at a designated time 2GB internal memory2GB internal memory Uses 2 AA batteriesUses 2 AA batteries Has ability to monitor 12 channels: Has ability to monitor 12 channels:

thermister, pressure transducer, snore, thermister, pressure transducer, snore, body position, SPO2, pleth, pulse, chest body position, SPO2, pleth, pulse, chest effort, abdominal effort, 2 limb channels effort, abdominal effort, 2 limb channels and 1 DC outputand 1 DC output

Nihon Kohden NomadNihon Kohden Nomad

Limitations:Limitations: Larger/heavier than most unitsLarger/heavier than most units Higher price pointHigher price point Costly to repairCostly to repair Difficult for patient to apply Difficult for patient to apply

themselvesthemselves

SleepView by CleveMedSleepView by CleveMed

SleepView by CleveMedSleepView by CleveMed

Features:Features: Cloud basedCloud based Easy patient applicationEasy patient application Very lightVery light Capable of recording 7 channels: Pulse Capable of recording 7 channels: Pulse

oximetry, heart rate, respiratory effort, oximetry, heart rate, respiratory effort, cannula based airflow, thermister based cannula based airflow, thermister based airflow, snore, and body positionairflow, snore, and body position

Uses 1 AAA batteryUses 1 AAA battery All necessary study supplies includedAll necessary study supplies included 1 GB internal memory1 GB internal memory

SleepView by CleveMedSleepView by CleveMed

Limitations:Limitations: Belt seemed to slip out of place Belt seemed to slip out of place

during recording resulting in a sub-during recording resulting in a sub-optimal signaloptimal signal

Cumbersome log in/ log out process Cumbersome log in/ log out process for downloading, scoring and for downloading, scoring and interpreting in one locationinterpreting in one location

Apnea Link Plus by ResMedApnea Link Plus by ResMed

Apnea Link Plus by ResMedApnea Link Plus by ResMed

Features:Features: 4 channels: nasal flow (and snore), 4 channels: nasal flow (and snore),

pulse, oxygen saturation, and pulse, oxygen saturation, and respiratory effortrespiratory effort

LightweightLightweight Easy patient applicationEasy patient application Uses 2 AA batteriesUses 2 AA batteries Ability to email report and recordingAbility to email report and recording Cost effectiveCost effective

Apnea Link Plus by ResMedApnea Link Plus by ResMed

Limitations:Limitations: No body position sensorNo body position sensor No numerical values when scoring No numerical values when scoring

desaturationsdesaturations

SUMMIT HST ALGORITHMSleep physician consult and HST ordered if

appropriateHST interpretedSleep clinic follow-up with initiation of auto-

CPAP 4-14 if indicatedIn-lab CPAP titration if auto-CPAP fails to

resolve symptoms If HST nondiagnostic then either repeat HST

or in-lab study ordered

HST INTERPRETATION HST INTERPRETATION TEMPLATETEMPLATE

Patient Name : Account number:

Home Sleep Testing Interpretation Patient’s reported sleep time and quality: Quality of raw data? Good Fair Poor Unacceptable Impression: No evidence of sleep disordered breathing Mild obstructive sleep apnea Moderate obstructive sleep apnea Severe obstructive sleep apnea Other: Plan: Sleep clinic follow up with review of results and

initiation of autoadjusting CPAP 4-14cm H20 In-lab CPAP titration secondary to Sleep clinic follow up with MD Other: Physician signature: Date:

WHERE IS SLEEP WHERE IS SLEEP MEDICINE HEADED IN MEDICINE HEADED IN

THE USA?THE USA?

THANK YOUTHANK YOU