A2Zz Volume 20 4

December 2011 | Volume 20 | Number 4

American Association of Sleep Technologists Technical Guideline for Positive Airway Pressure Acclimation and Desensitization Free-running Rhythm in Sighted People What Sleep Technologists Should Know About Oral Appliances Thirty Years of CPAP Therapy

A Publication of the American Association of Sleep Technologists

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4

DECEMBER2011 | VoluME20Number4

FROm The eDiTOR

By Cindy Kistner, BS, RST, RPSGT, REEGTig News! Read All About It! A2Zzz Goes Online! As the last printed issue of A2Zzz, this edition of the magazine represents another turning point in the long history of the official publication of the American Association of Sleep Technologists (AAST). In 2012 A2Zzz will become an online only, interactive, educational resource that will continue to keep members informed about the latest changes in AAST IMMEDIATE the sleep field while providing ongoPAST PRESIDENT CINDY KISTNER, BS, ing opportunities to earn continuing RST, RPSGT, REEGT education credits (CECs). This is the latest change to the magazine, which began in June 1978 as the small newsletter Sleepwatchers. The publication evolved into The Journal of Polysomnographic Technology in 1986 before eventually becoming A2Zzz. In 2009 the AAST unveiled a new logo, cover and overall design for the magazine, giving each issue a consistent appearance that represents the AASTs commitment to professional excellence. Now the magazine will become an online only publication, reflecting recent changes in digital technology and current trends in the publishing industry. Recognizing the need to be wise stewards of the economic resources that have been entrusted to the AAST by members, the board of directors embraces this transition to an online only format for A2Zzz. This decision also was supported by the membership in an August 2011 survey. This wise utilization of the AASTs resources is one example of our ongoing commitment to ensure that the AAST remains the leading membership organization for sleep technologists as the professional landscape continues to change. I hope you enjoy reading this and all future issues of A2Zzz. The new dynamic format of the magazine allows you to turn the page on your screen, quickly browse the content and search for keywords, click on an ad to visit the companys website, and view the full magazine on any mobile or tablet device. I am grateful for all of the members who continue to submit original articles for publication in the magazine, making A2Zzz the premier publication written by and for sleep technologists. Remember to complete the AAST CEC Evaluation Form and submit it to the national office by March 31, 2012, to receive 1.5 AAST CECs for reading this issue. Go online and read A2Zzz today!!!

B

TAble OF COnTenTSFrom the President............................................................... 8 AAST News Briefs ................................................................. 9 American Association of Sleep Technologists Technical Guideline for PAP Acclimation and Desensitization ... 10-13 Continuing Education Credit Offering ............................... 14 AAST CEC Evaluation Form ................................................15 Free-Running Rhythm in Sighted People .................... 16-18 Patient Care Practices Following Lights On ................ 20-21 Case Study: Obstructive Sleep Apnea and Oral Appliance ....................................................... 22-23 Technical Corner: What Sleep Technologists Should Know About Oral Appliances ...........................24-27 Manager's Desk: Effective Communication in Difficult Conversations ............................................. 28-29 Ask Dr. Jim and Tracy .........................................................30 Thirty Years of CPAP Therapy............................................. 31 The Societal Burden of Sleep Deprivation and Undiagnosed Sleep Apnea ................................... 32-33 In the Moonlight .................................................................34 Education & Training Update .............................................35 Scoring Manual Update .....................................................36 Certification Update ........................................................... 37 Sleep Fragments ................................................................38

Sleep Well,

September

2010 | Volume

19 | Number

3

Possib Nitric

Risk The

Insomnia al Loss with le Neuron Upper Apnea and ctive Sleep Oxide, Obstru mation Facilities for Sleep Airway Inflam Techniques Strategy and Management A, B, C of PAP DIY EEGT Generation and the Pursui t of theTechno logists

Second

Alpha Rhythm

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Submit an original article for publication in A2Zzz. See page 6 for details.

A2 Zzz 20.4 | December 2011

ONLINE LEARNING CENTERBe in command with education on demandThe AAST Online Learning Center has been updated and enhanced to make it even more valuable as an educational resource for sleep technicians and sleep technologists. Get exceptional learning opportunities from the leader in the profession of sleep technology.

VISIT THE NEW AAST

Informative | Convenient | Relevant | Innovative | AffordableOnline Learning Modules AAST Online Learning Modules provide the most relevant and current information from AAST courses and workshops. Each learning module includes a narrated presentation, educational references and a post-test for AAST Continuing Education Credit (CEC). Current modules cover a wide variety of topics such as CPAP titration, scoring of sleep onset and portable monitoring and new modules are added regularly. Learning modules are compatible with iPhone and iPad. Online Practice Exams Test your understanding of sleep and sleep disorders with the AAST Online Practice Exams. Ten practice exams will help you prepare for the certified polysomnographic technician (CPSGT) and registered polysomnographic technologist (RPSGT) exams. The interactive exams provide you with immediate feedback and allow you to learn at your own pace.

Visit the new AAST Online Learning Center for education on demand: the educational resources you need, available whenever you want them. Go to www.aastweb.org/LearningCenter and start learning today!

6

OFFICIAL PUBLICATION OF ThE AmeRiCAn ASSOCiATiOn OF SleeP TeChnOlOGiSTS (AAST)

AbOuT A2Zzz

A2Zzz is published quarterly by the American Association of Sleep Technologists (AAST), 2510 North Frontage Road, Darien, IL 60561. Postage paid at Eau Claire, Wisconsin. Learning Objectives: Readers of A2Zzz should be able to do the following: Analyze articles for information that improves their understanding of sleep, sleep disorders, sleep studies and treatment options Interpret this information to determine how it relates to the practice of sleep technology Decide how this information can improve the techniques and procedures that are used to evaluate sleep disorders patients and treatments Apply this knowledge in the practice of sleep technology Annual Subscription Rates: Subscription to A2Zzz is included as a member benefit of the AAST. Subscription rates (non-members and institutions) for 2011, Volume 20: $60, outside U.S. $140. Submissions: Original articles submitted by AAST members and by invited authors will be considered for publication. Published articles become the permanent property of the AAST. Change of Address: Changes of address should be submitted four to six weeks in advance of the change to ensure uninterrupted service. Members of the AAST can edit their address online when they log in at www. aastweb.org. Subscribers also can send to the AAST national office their new address, the effective date of change and a copy of the current mailing label showing the old address. Postmaster: Send change of address to AAST, 2510 North Frontage Road, Darien, IL 60561. Missing Issue Claims: Claims for missing issues must be submitted within 60 days of the publication date by fax to the AAST at (630) 737-9788 or by e-mail to [email protected] Permission to Use and Reproduce: A2Zzz is published quarterly by the AAST, all rights reserved. Permission to copy or republish A2Zzz material is limited by restrictions. Visit www.aastweb.org to view the full A2Zzz permissions and use policy. Reprints: Contact the AAST national office for orders of 100 reprints or more.

Advertising: Advertising is available in A2Zzz. Please contact the AAST national office for information concerning A2Zzz rates and policies, or find more details online at www.aastweb.org. Disclaimer: The statements and opinions contained in articles and editorials in this magazine are solely those of the authors thereof and not of the American Association of Sleep Technologists (AAST); the American Academy of Sleep Medicine (AASM), which provides management services for the AAST; or of either organizations officers, regents, members or employees. The appearance of products and services, and statements contained in advertisements, are the sole responsibility of the advertisers, including any descriptions of effectiveness, quality or safety. The Editor; Managing Editor; AAST; AASM; and each organizations officers, regents, members and employees disclaim all responsibility for any injury to persons or property resulting from any ideas, products or services referred to in articles or advertisements in this magazine. Mission: To promote and advance the sleep technology profession through the continued development of educational, technical and clinical excellence in sleep disorders.

Vision: To preserve the autonomy and future of the sleep technology profession by providing educational and professional pathways with innovative approaches that promote professional growth and development Purpose: To provide a voice for the professionals who ensure the safe and accurate assessment and treatment of sleep disorders 2510 North Frontage Road Darien, IL 60561 Phone: (630) 737-9704 Fax: (630) 737-9788 E-mail: [email protected] Web: http://www.aastweb.org 2011 American Association of Sleep Technologists

Share your expertise with colleagues in the profession of sleep technology by submitting an original article to A2Zzz. Read the A2Zzz Writers Guidelines at http://www.aastweb.org/A2ZzzGenInfo.aspx. To propose an article topic or to get more information, send an e-mail to [email protected].

Submit aN artiCle to A2Zzz

COnTRibuTORSeDitorCindy Kistner, BS, RST, RPSGT, REEGT

SpeCial FeatureSAllen Moses, DDS Tracy Nasca James OBrien, MD Samuel Sealy

maNagiNg eDitorThomas M. Heffron

David Gregory, RPSGT Henry Johns, RPSGT, CRT Douglas Kirsch, MD Jennifer May, RST, RPSGT David Wolfe, MSEd, RST, RPSGT, RT

SeNior WriterS

Regina Patrick, RST, RPSGT

CartooNiSt

CoNtributiNg WriterS

Barbara Ludwig-Cull, RST, RPSGT Jim Phelps

Richard Bonato, PhD, MA, RPSGT Joanne Hebding, RPSGT Anglee Leviner, RPSGT Wayne Peacock, RST, RPSGT Jacquelyn Polito, MHA, RPSGT, REEGT Brant Steffes, RPSGT

CeC artiCle reVieW paNelKaren Allen, RPSGT, CRT Eric Bell, PsyD Richard Bonato, PhD, MA, RPSGT Rita Brooks, RST, RPSGT Todd Eiken, RPSGT

A2Zzz publishes articles that relate to the profession of sleep technology and informs members about recent and upcoming activities of the American Association of Sleep Technologists (AAST).


8

FROm The PReSiDenT

By Melinda Trimble, RST, RPSGT, LRCPhat a wonderful year we have had in 2011. It has been an eventful year for both the American Association of Sleep Technologists (AAST) and our membership, and I am grateful for all of our members who have invested countless hours of their personal time by volunteering to serve on AAST AAST PRESIDENT committees, task MELINDA TRIMBLE, RST, RPSGT, LRCP forces and the board of directors. It inspires me to see this level of commitment among our members, and it is this passionate dedication to the profession that will help us continue to advance sleep technology in the years ahead. In August the AAST board of directors began the journey of going through a strategic planning process, which has caused me to spend a lot of time reflecting on the AASTs mission and vision statements. These statements are printed in every issue of this magazine on p. 6, and I encourage you to become familiar with them. In summary, these two statements describe how the AAST is committed to promoting excellence in sleep technology and preserving the future of the profession. I can tell you without hesitation that the AAST has been true to this mission and vision in 2011. The AAST board of directors has abided by an uncompromising code of integrity, and I am proud of all that we have accomplished this year. We have many challenges ahead of us in the coming year, and I am convinced that this board of directors will meet those challenges with courage, which gives us the moral and mental strength to do what is right, even in the face of personal or professional adversity. Throughout its 33-year history, the AAST has been at the forefront of the battle to preserve our profession. In recent years, the AAST has invested more than $250,000 in the legislative defense of sleep technology. Our mission is to help guide our membership during these challenging times. The entire sleep field is continuing to evolve, as out of center sleep testing (OCST) becomes more prominent and national health care reform promotes cost containment and long-term outcomes. The AAST is prepared to lead the sleep technology profession through this period of transition, and in the coming year you will see many new and innovative educational programs that will help our members adapt to their changing professional roles and prosper in the sleep center of the future. The complexity of sleep-related technology is growing at an unparalleled rate, and

W

It has been an eventful year for both the American Association of Sleep Technologists (AAST) and our membership...

we owe it to ourselves to learn, grow and advance in our careers. We want our members to be able to compete, and flourish, in an increasingly competitive job marketplace through continued education and professional growth. As a professional membership society, the AAST provides educational programs for all sleep technologists, from the novice to the veteran. Education is what we do. Our aim is to give every sleep technician and sleep technologist the opportunity to obtain the educational tools they need at a reasonable fee and in a manner that is conducive to success. The AAST is well aware that these are difficult economic times, which can make it hard to obtain the continuing education that is necessary for professional growth. That is why the AAST slashed prices on its CEC products during the recent holiday sale, gave members an end-ofthe-year opportunity to earn 2.0 free CECs in the AAST Online Learning Center, and is continuing to re-evaluate the pricing structure of our educational resources as we head into the New Year. Im also proud to report that the AAST will again provide a wealth of benefits to members in 2012 without raising membership dues, which remain among the lowest of any allied health care professional society. If you havent renewed your AAST membership for 2012, I encourage you to go online to www.aastweb.org and renew today. Your AAST membership is an investment in both your career and the profession. As the AAST president, I have made a commitment to speak at several meetings of state and regional sleep societies in 2012. My hope is to meet as many of our members as possible and to keep everyone up to date on what is happening within our profession. I look forward to meeting and talking to many of you. May the New Year bring you peace and joy. Until we meet again,

Melinda Trimble


9

AASTNEWS BRIEFSThe current issue of A2Zzz, volume 20, number 4, will be the final printed issue of the magazine, which is the official publication of the AAST. Beginning in 2012 with volume 21, A2Zzz will be available only on the AAST website as a dynamic, interactive online magazine. The new enhanced edition of A2Zzz allows you to turn the page on your screen, quickly browse the content and search for keywords, click on an ad to visit the companys website, and view the magazine on any mobile or tablet device. As the AAST embraces a new online-only format for A2Zzz, members can continue to expect each issue of the magazine to be filled with relevant, insightful and educational articles written by and for sleep technologists. By reading A2Zzz, members also will be able to earn 2.0 continuing education credits (CECs) per issue in 2012- for a total of up to 8.00 AAST CECs per year. Members can preview the new enhanced online edition of A2Zzz when you access the magazine on the AAST website at www.aastweb.org.

a2ZZZ goeS oNliNe oNlY iN 2012

Advance your career and expand your professional opportunities by renewing your membership with the American Association of Sleep Technologists (AAST), which has been the leading voice for the sleep technology profession for more than three decades. Renew today to continue receiving a complimentary subscription to A2Zzz, exclusive opportunities to earn continuing education credits (CECs), members-only discounts on educational resources such as new online learning modules, national and local representation, and much more! Log on to the AAST website today at www.aastweb.org to renew your membership and verify your email address. For more information contact the AAST Membership Department at 630-737-9704 or [email protected].

reNeW Your aaSt memberSHip For 2012

2012 eleCtioN: Call For NomiNatioNS

aaSt NeW DireCtioNS iN Sleep apNea CourSe iS marCH 24-25

The AAST course Advances in Sleep Technology: New Directions in Sleep Apnea Evaluation and Therapy will be held March 24-25, 2012, at the national office in Darien, Ill., a suburb of Chicago. An expert faculty will discuss emerging technologies used to evaluate and treat sleep-related breathing disorders, including cardiopulmonary coupling, pulse transit times, pulse arterial tonometry measures, nasal expiratory resistance devices and hypoglossal nerve stimulation. Participants will earn up to 14.00 hours of continuing education credits (CECs); an application has been submitted to the American Association for Respiratory Care (AARC) for Continuing Respiratory Care Education (CRCE) contact hours for respiratory therapists. Visit the AAST website at www.aastweb.org to register online and for more information. Save on registration fees by registering on or before Feb. 24, 2012; space is limited, so please register early.

The Nominations and Elections Committee is currently accepting nominations for service on the AAST Board of Directors. To be considered for these positions, individuals must be a regular member of the AAST in good standing for three consecutive years, work full-time in the sleep technology profession and have five years of experience working in the sleep technology profession. Interested candidates are reminded to consider the time commitment associated with these positions. Members of the AAST Board of Directors are required to attend up to five face-to-face meetings (that require weekend travel) annually over the three-year term. For additional information about the Call for Nominations, visit the AAST website at www.aastweb.org. The deadline to submit a candidate packet is Thursday, Jan. 12, 2012.

NomiNate a member For aN aWarD

SpeCial oFFer: reCruit ColleagueS to JoiN tHe aaSt

The AAST is offering a special incentive for you to recruit colleagues to join the AAST. Each time you refer a new Regular Member for the 2012 membership year, the AAST will reward you with a coupon for a free AAST webinar archive CD-ROM (including free shipping and handling). Each member referral also enters you into a Grand Prize Drawing to win a complimentary registration to the general session of the 2013 AAST Annual Meeting (including up to three nights hotel and travel expenses). Go to www.aastweb.org for complete details about the Member-Get-A-Member Campaign.

Each year the AAST recognizes individual members for their professional excellence, service and commitment to the association and to the sleep technology profession. AAST award recipients will be recognized in an awards ceremony conducted at the AAST 34th Annual Meeting and will receive complimentary general meeting registration. AAST members are encouraged to recognize other members' contributions and achievements by submitting a 2012 Award Nomination Form and a brief narrative endorsing their nomination to [email protected] by Jan. 31, 2012. Complete information about the awards and nomination process is available on the AAST website at www. aastweb.org.

VoluNteer to SerVe oN a Committee

Become more involved in the activities of the AAST and help advance the sleep technology profession by volunteering to serve on an AAST standing committee. Find all of the relevant information and instructions in the 2012 Call for Volunteers on the AAST website at www.aastweb.org. Interested members should note that service on a standing committee is a three-year appointment, which will take effect upon the approval of the Board of Directors. Members who submit their documents by Jan. 31, 2012, will be considered for appointment.


10

ameriCaN aSSoCiatioN oF Sleep teCHNologiStS teCHNiCal guiDeliNe For poSitiVe airWaY preSSure aCClimatioN aND DeSeNSitiZatioNositive Airway Pressure (PAP) applied through a nasal, oral, or oronasal interface during sleep is the preferred treatment for patients with moderate to severe Obstructive Sleep Apnea (OSA).1 American Academy of Sleep Medicine clinical guidelines indicate that all potential PAP titration candidates should receive adequate PAP education, hands-on demonstration, careful mask fitting, and acclimatization prior to titration.2 The sleep technologist is an integral member of the team caring for patients with OSA and is tasked with providing education and care for patients undergoing PAP titration in the sleep center. Acclimation should include education that provides indications and rationale for PAP usage and potential side effects, and careful fitting of the PAP interface (i.e., nasal mask, nasal pillows, full-face mask). The patient should be acclimated to PAP, wearing the interface with the pressure on, prior to lights off.3 PAP desensitization, generally conducted during daytime sessions with a sleep technologist, is used when patients who would benefit from PAP therapy have difficulty acclimating to therapy. This guideline describes the procedure for determining the appropriate PAP mask or interface type and fit, discusses techniques for optimally acclimating patients to PAP therapy and provides methods for PAP desensitization when it is necessary to assist patients to utilize PAP therapy.

P

eQuipmeNt aND SupplieS PAP devices Humidifiers Interface sizing gauges Interfaces, headgear and hoses/valves Chin straps

pap aCClimatioN

All patients who undergo a sleep study with PAP therapy, including CPAP, Bi-level PAP, Auto PAP, Servo Ventilation or a split-night PAP study require acclimation to PAP. Acclimating to PAP can be maximized by offering interface options, positive feedback, expression of empathy and understanding, and reassurance and praise for even minimal effort. Introducing PAP prior to beginning the titration study, giving the patient control over the mask and allowing him to touch or reposition the mask as needed, and using distraction measures such as television, radio, or counting are useful acclimating techniques.4

prepariNg tHe patieNt For Cpap

DeFiNitioNS

Acclimation Techniques used to familiarize patients with PAP therapy Auto PAP (APAP) Automatic Positive Airway Pressure; device designed to provide air pressure at a customized, regularly adjusted level Bi-level PAP (BPAP) positive airway pressure delivered with differing pressures for inhalation (IPAP) and exhalation (EPAP) CPAP Continuous Positive Airway Pressure; device designed to deliver positive airway pressure at a consistent level Desensitization Techniques used to assist patients having difficulty acclimating to PAP therapy Full Face Mask Generic term for any PAP mask or interface that covers both the nostrils and the mouth Leak Measured in Liters/minute (L/min); unintentional leak in the patient PAP circuit, often caused by a poor interface seal or mouth leaks Nasal Interface Generic term for any PAP mask or interface that covers only the nostrils OSA Obstructive Sleep Apnea PAP Positive Airway Pressure therapy using CPAP, Bi-level PAP, Auto CPAP, or SV Servo Ventilation Adaptive or Automatic Servo Ventilation (dependent on manufacturer) device that provides noninvasive ventilatory pressure support based on the patients breath-bybreath needs Split Night Study Two-part study comprised of diagnostic baseline and a PAP treatment component

PAP acclimation should be undertaken prior to electrode application in the patients bedroom. Begin by reviewing the physiology of OSA and the rationale for PAP and how it works with the patient. A PAP educational video may be a useful tool to assist with patient education. Research findings indicate that patients who have been educated on treatment interventions as well as the disease state of obstructive sleep apnea show increased adherence to PAP over patients who were not provided education and support.4

iNterFaCe SeleCtioN aND maSK FittiNg

Unless a specific interface is specified by the ordering physician, begin the process by offering the patient several nasal masks. For patients requiring PAP desensitization, the interface can make or break the success of the encounter. It is therefore very important that the best interface option is chosen for the patient. It is equally important to inform the patient that there are many different types of interfaces available. Inform the patient that interface choice tends to be personal preference, that there are pros and cons to all interfaces, and that finding the best interface may require some fine tuning. Some things to consider when choosing an interface for a patient include nasal or facial abnormalities, facial hair, and claustrophobia. If a patient is claustrophobic, choosing a nasal interface style that does not interfere with the patients field of vision is a good choice. Patients with facial hair may do better with a nasal pillow interface. (Note: Do not use nasal pillows for ASV titrations, per manufacturers guidelines.) The patient should be given two to three options to choose from. Determine if the patient is a mouth breather. Some patients are mouth breathers due to an anatomical problem


11such as nasal polyps or cysts or structural problems from broken nasal cartilage. Others may be habitual mouth breathers who actually can breathe through their nose. Ask the patient to attempt breathing through his nose, and if he is able to do so begin with a nasal interface. If nasal breathing is impossible due to an anatomical or structural problem, fit the patient with a full face mask. Once an interface style has been selected, the technologist must determine the proper size for the patient. Utilize a sizing gauge to determine the patients mask size. The correct mask size is essential to limit mask leaks. The goal is to fit the patient with an interface that is comfortable, seals well and does not leak when the blower is on. Try different mask styles if necessary to reach this goal. These efforts will serve to minimize the side effects of PAP and therefore maximize therapeutic value, compliance and the patients quality of life. that PAP therapy is generally well tolerated and he should not hesitate to let you know if there are any problems. Patients often awaken during a titration and complain of the high pressures. The pressure may be reduced while the patient is awake in order to facilitate the return to sleep. Once the patient returns to sleep, pressures should be increased gradually but expeditiously to the required therapeutic level. If a patient is unable to tolerate and chooses to discontinue PAP therapy, the masks/interfaces used and reasons for the patients inability to tolerate PAP therapy must be documented for the physician. This documentation is valuable for the physician who will determine if desensitization is an option for the patient and for the technologist who later attempts desensitization therapy with the patient. When a patient is unable to acclimate to PAP during a titration study, desensitization carried out in the PAP clinic and/ or at home is often successful.

aCClimatiNg tHe patieNt to pap preSSure

PAP therapy should be introduced gradually. Begin by allowing the patient to hold the interface to get a feel for it. Have patient hold the mask to his nose and breathe through it, without the PAP hose connected. Instruct the patient to close his mouth and breathe in and out through his nose. Connect the nasal exhaust port to the hose and interface. Select a CPAP pressure of about 4.0 cm/H2O to begin with. For Bi-level PAP start at 8 IPAP/4 EPAP. Have the patient hold his hand over the interface opening to feel the air pressure, then have him place the mask over his nose and instruct him to breathe in and out through his nose with his mouth closed. Have the patient practice breathing with the interface for approximately 3 to 5 minutes, while positively reinforcing proper breathing techniques. Offer encouragement, such as: The next step is to let you experience a range of pressures so you will know what to expect tonight, or in the case of a split night study if we decide to use CPAP tonight during the study. It is new and different, but I know you can do this. If the patient is having difficulty acclimating to PAP therapy, ask questions to pinpoint the specific problem. Issues such as dryness, interface discomfort, nasal congestion, difficulty exhaling and/or leaks must be addressed promptly. If the patient is having difficulty with exhalation against the pressure, consider using pressure relief. Once the patient is comfortable with the PAP pressure, prepare him for the PSG recording. Next fit the PAP mask and headgear, taking care not to over-tighten the mask. Instruct the patient how to connect and disconnect the nasal interface from the PAP hose connection. This will give him a sense of control if he needs to discontinue the PAP during the night. Be sure to minimize leaks and teach the patient to re-seat the mask if he feels a leak around the seal. Explain the difference between the exhalation port leak (which is essential for release of carbon dioxide) and a leak around the seal (which needs adjustment). If the patient is unable to keep his mouth closed consider a chinstrap or a full face mask. Prior to lights out remind the patient to breathe in and out through the nose with his mouth closed. Repeating this instruction increases the likelihood that the patient will retain this important information. Inform the patient you will be available for help throughout the night and that he should tell you if he is having any problems during the night so that you can make any necessary adjustments to the equipment or mask. Explain

improViNg patieNt ComFort aND toleraNCe DuriNg pap titratioN

Leaks occur and can be normal, but commonly are due to ill-fitting headgear, improper mask size, defective tubing or attachments, or mouth leak. Leak rate charts specific to the mask being used are useful to determine an acceptable leak value. Determine the reason or reasons for the leak and attempt to reduce the leak by reseating the mask, assuring that the mask is not over tightened, using a chin strap or full face mask if mouth leak is evident, or trying a different mask or interface. Leaks at the eyes or pressure on the bridge of the nose may be resolved using a mask with an adjustment at the bridge of the nose. There should be several different types of PAP interfaces (i.e., nasal mask, nasal pillows, full-face/oronasal mask) and accessories (chinstrap, heated humidifier) available if the patient encounters problems (e.g., mouth leak, nasal congestion, or oronasal dryness) during the night. If the patient is struggling with the PAP pressure and is using nasal pillows, try switching to a standard nasal mask. Using pressure relief technology or switching to bi-level therapy (BPAP) may allow the patient to tolerate PAP. Pressure waveform modification technologies (such as pressure relief ) may improve patient comfort and adherence with PAP.1 BPAP is an optional therapy in some cases where high pressure is needed and the patient experiences difficulty exhaling against a fixed pressure.1 Complaints of dryness in the nose, throat, and mouth are commonly due to inadequate humidification. Heated humidification is the best method for addressing complaints of dryness. If the patient complains of a burning sensation in their nose, the temperature on the heater may need to be increased. If the patient wakes up complaining of dryness in the throat or mouth, which is likely caused by mouth breathing, adding a chinstrap along with increased heat may correct the problem. Note, however, that too much humidification can cause a rain out effect (water buildup) in the tubing and/or interface.

Continued on Page 12

uSe aND Care oF pap eQuipmeNt

Patients should be educated about the function, care, and maintenance of their equipment, the benefits of PAP therapy, and potential problems.5 Selection of the most appropriate PAP interface, use of heated humidification and a thorough educa-


12tional program that encompasses all members of the healthcare team are the primary methods shown to improve PAP utilization. The use and care of PAP equipment, including explanation of the parts and assembly of all equipment, how and when to clean equipment, and the importance of daily/nightly use, should be discussed in detail with the patient or caregiver, preferably following the PAP titration study.5 Patients should be informed of common complications of PAP that may cause adherence issues and instructed to contact their care provider or the sleep center if they encounter any of these problems. It is helpful to assure patients that these complications can be addressed in a variety of ways. PAP compliance is best when patients are educated about their disorder and treatment and the education process begins with the primary referring physician. Establishing a standard practice for PAP therapy that includes education and cooperation from all care providers is essential.6 Troubleshooting and addressing problems related to PAP use, managing side effects, and utilizing methods to increase PAP adherence should be part of the close follow-up on patients using PAP, particularly in the first week of therapy.7 The most common reasons for non-compliance to PAP are inadequate patient education interface difficulties abbreviated titration (an unsuccessful split night) difficulties falling asleep arousals claustrophobia/anxiety airway dryness/irritation difficulty exhaling against the pressure worries about social acceptance To begin your assessment of compliance issues, it is helpful to determine if the patient is accepting of treatment. Does the patient understand the consequences of untreated sleep apnea and the benefits of therapy? Interface issues can be resolved. Interaction with the patient is essential if you are trying to resolve an interface issue. Some common discussion points that will help you to resolve an interface issue include these questions. Does the patient find the mask comfortable? Does it fit properly? Does the patient like the style? Difficulty exhaling against the pressure can be alleviated using a variety of techniques. Decreasing pressure, particularly as the patient is falling asleep, can be accomplished using the ramping function of the PAP device. Assure that the ramp function is set appropriately, and show the patient how to reset the ramping function if he wakes and has difficulty tolerating the pressure during the night. Pressure relief and bi-level settings are also very useful methods of addressing this issue. Auto-titrating PAP (APAP) can also be considered in the management of OSA in CPAP intolerant patients.1 Dry and irritated airways commonly occur in patients using PAP. Increasing ambient humidity with a cool pass over or heated humidifier should be standard for all patients. The interface may contribute to airway irritation as well; people with chronic sinus problems may have difficulty using a nasal pillow interface. Airway dryness issues are generally best addressed using heated humidification. Keep in mind, however, that there may be other problems contributing to airway irritation. Cleanliness of equipment, particularly the humidifier, method of cleaning, or the water used in the humidifier can also cause airway irritation. Verify that the patient is using distilled water in the humidification system. Tap water often contains chlorine and can cause irritation and burning sensations in the airway. Assure that the patient is not cleaning the mask, hose or humidifier with harsh chemicals, and that he is rinsing the equipment thoroughly after cleaning. Mouth breathing can also contribute to airway dryness. Habitual or essential mouth breathing can be identified by having the patient demonstrate his ability to breathe through his nose and assessing if the patients nasal airflow is actually limited. Mouth breathing can also be assessed by watching the patient to see if he mouth breathes while you are explaining procedures. Using a chin strap to keep the mouth closed will improve complaints of a dry mouth and throat. When mouth breathing is a result of a nasal deformity that truly limits or prevents the patient from breathing through the nose, a full face mask will allow humidification to reach the airway. Claustrophobia and anxiety can sometimes be alleviated by using a different interface. Nasal pillows or interfaces that do not obstruct patient vision are often helpful. Occasionally, a full face mask may be a better choice for a claustrophobic patient. A full face mask may also be better tolerated by scuba divers and firefighters, who are accustomed to breathing through the mouth. The goal is to alleviate any issues that the patient may be experiencing. It is important to find the most comfortable and leak-free interface for each patient, address pressure and dryness issues, and provide the education necessary to improve compliance with therapy. Claustrophobia and inability to tolerate PAP pressures are the primary reasons that patients undergo PAP desensitization.

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pap CompliaNCe

Is nasal obstruction a problem? Does the patient have a deviated septum, allergies, or sinus problems? Is the patient able to breathe through his nose? Other interface issues to consider are air leakage and skin irritation or skin breakdown. Air leakage near the eyes can cause conjunctivitis. Skin irritation and breakdown are most often caused by over tightening of the interface. Both issues are easily resolved by fitting a more appropriate interface for the patient. Skin issues can be addressed by utilizing a different interface, such as nasal pillows. Some patients switch between a nasal mask and nasal pillows routinely to avoid skin irritation and breakdown issues. Mask leaks are commonly associated with ill-fitting headgear, improper mask size, or defective tubing or attachments, and can be corrected with some diligence on the part of the technologist.

pap DeSeNSitiZatioN

PAP desensitization is generally undertaken with patients who were unable to tolerate PAP during a titration study due to claustrophobia or inability to tolerate PAP pressures. On occasion patients who were successfully titrated find they cannot use PAP at home and are referred for desensitization. PAP desensitization can be performed in the sleep clinic, sleep center, or the patient home. It is most often initiated in the sleep clinic or sleep center, and continued in the patients home until the patient has acclimated to the mask and pressure sufficiently to return for a PAP titration study. PAP desensitization initiated in the sleep clinic or sleep center should be performed in a quiet area with a recliner or in a patient bedroom.


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DeSeNSitiZatioN teCHNiQueS1. 2. 3. Measure the patient carefully and select an appropriate interface and head gear. Allow the patient to handle the mask himself, holding it to his face to assess fit, prior to connecting the mask to the hose or PAP instrument. Connect the hose to the mask and PAP instrument, and allowing the patient to hold the mask to his face gradually introduce pressure at 2-4 cm/H2O. It is important to allow the patient to have control of the mask. Once the patient is comfortable holding the mask to his face and breathing with PAP at a low pressure, turn off the pressure and fit the mask and headgear. Show the patient how to disconnect the hose from the mask, and have him recline in a recliner or lie supine on a bed. Re-initiate pressure at 2-4 cm/H2O using heated humidity while the patient is lying down. Offer encouragement, such as, It looks like you are breathing comfortably at this pressure or You are doing fine; remember that this is going to help your breathing while you sleep. If the patient is having any difficulty at this low pressure, refrain from increasing the pressure. In some cases distraction techniques such as watching TV or reading may help the patient to tolerate the procedure. If the patient is tolerating the low pressure well, inform him that you will be gradually increasing the pressure. Remind him that he can disconnect the hose if the pressure becomes intolerable. This allows the patient to remain in control of the process.

16. Send the patient home with written instructions for the process he is to follow at home. Some patients will need to become tolerant of the mask alone at home. This can be accomplished by instructing the patient to wear the mask in the evening while watching TV until he can tolerate it for at least 30 minutes. Once the mask is tolerated, desensitization in the sleep clinic or sleep center can be attempted again. 17. If the patient tolerated the mask but had difficulty with the pressure, consider sending him home with a PAP device set to approximately 8 cm/H2O and a 30-minute ramp time. Instruct the patient on how to reset the ramp to lower the pressure at any time, and encourage him to practice outside of the sleep period, perhaps while reclining and watching TV in the evening until he is able to tolerate the pressure at 8 cm/H2O. Once this is accomplished, the patient can be scheduled for a PAP titration study.

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Because the patient is awake and aware, the desensitization process can be difficult. The technologist must be patient and encouraging. Explain to the patient that with practice and time, most patients are able to tolerate and benefit from pap therapy. Desensitization techniques, interface options, pressure relief technology, and humidification along with encouragement from the technologist and the expression of empathy, understanding and praise for the patients efforts go a long way toward assisting the patient to achieve PAP therapy and ultimately PAP compliance.4

reFereNCeS1. Epstein LJ, Kristo D, Strollo PJ, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Journal of Clinical Sleep Medicine 2009; 5(3):268. Kushida CA, Chediak AC, Berry RB, Brown KL, et al. Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. Journal of Clinical Sleep Medicine 2008; 4:160. Kushida CA, Chediak AC, Berry RB, Brown KL, et al. Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. Journal of Clinical Sleep Medicine 2008; 4:161. American Association of Sleep Technologists. AAST technical guideline for positive airway pressure (PAP) adherence and follow-up care. A2ZZZ 2009; 18(2):16. Epstein LJ, Kristo D, Strollo PJ, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Journal of Clinical Sleep Med 2009;5(3):270. American Association of Sleep Technologists. AAST technical guideline for positive airway pressure (PAP) adherence and follow-up care. A2ZZZ 2009; 18(2):17. Kushida CA, Chediak AC, Berry RB, Brown KL, et al. Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. Journal of Clinical Sleep Medicine 2008; 4:168.

13. When the patient is able to tolerate 8 cm/H2O for approximately 15 minutes, the desensitization is considered successful. When desensitization is successful, the patient should be able to tolerate a PAP titration study. 14. At the conclusion of the desensitization, ask the patient to summarize his experience. Document your assessment as well as the patients responses. 15. If the patient is having difficulty with the mask/interface or does not tolerate the desensitization procedure in the sleep clinic or sleep center, consider sending the patient home with the PAP equipment to continue the process at home for a period of one to two weeks.

Verify that there are no interface leaks or other issues prior to beginning to increase PAP pressure. 9. Increase pressures gradually in 1 cm increments in a ramping fashion, carefully monitoring patient reaction and tolerance. In general pressures should be increased to about 8 cm/H2O during the desensitization process. 10. Check for leaks and adjust interface fit if necessary, changing interface styles as needed. Utilize a chin strap or full face mask if mouth breathing is occurring. 11. If the patient is having difficulty tolerating higher pressures, particularly exhaling against the pressure, try using pressure relief or bi-level PAP. 12. Remember to continue to reassure the patient and reinforce his success. For example, You are doing well, keep it up. It is important to make this a positive experience for the patient.

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CoNtiNuiNg eDuCatioN CreDit oFFeriNgINStRuCtIoNS FoR EaRNINg CREDIt

Sleep professionals who read A2Zzz and submit the AAST CEC Evaluation Form by the deadline can earn 1.50 AAST Continuing Education Credits (CECs) per issue for up to 6.00 AAST CECs per year. AAST CECs are accepted by the American Board of Sleep Medicine (ABSM) and the Board of Registered Polysomnographic Technologists (BRPT). To earn AAST CECs, carefully read four of the designated CEC articles from the list below and complete the evaluation form on the next page. You must fax your completed form to the AAST national office, or have it postmarked, by the deadline of March 31, 2012. After the successful completion of this educational activity, a confirmation letter acknowledging that you have earned 1.50 AAST CECs will be sent six to eight weeks after the deadline to the email address that you have on file with the AAST.

CoSt

The A2Zzz continuing education credit offering is a free benefit for AAST members. An individual who is not an AAST member is required to become an A2Zzz subscriber and pay a $20 administrative fee with each AAST CEC Evaluation Form that he or she submits. Non-members who do not have an A2Zzz subscription must contact the AAST national office to become a subscriber.

StatEMENt oF appRoVal

This activity has been planned and implemented by the AAST Board of Directors to meet the educational needs of sleep technologists. AAST CECs are accepted by the American Board of Sleep Medicine (ABSM) and the Board of Registered Polysomnographic Technologists (BRPT). Individuals should only claim credit for the articles that he or she actually reads and evaluates for this educational activity. A2Zzz provides current sleep-related information that is relevant to sleep technologists. The magazine also informs readers about recent and upcoming activities of the AAST. CEC articles should benefit readers in their practice of sleep technology or in their management and administration of a sleep disorders center. Readers of A2Zzz should be able to do the following: Analyze articles for information that improves their understanding of sleep, sleep disorders, sleep studies and treatment options Interpret this information to determine how it relates to the practice of sleep technology Decide how this information can improve the techniques and procedures that are used to evaluate sleep disorders patients and treatments Apply this knowledge in the practice of sleep technology

StatEMENt oF EDuCatIoNal puRpoSE/oVERall EDuCatIoNal oBjECtIVES

Read and evaluate four of the following articles to earn 1.5 AAST CECs: Free-running Rhythm in Sighted People Objective: Understand how a free-running rhythm in a sighted person may easily be misdiagnosed Patient Care Practices Following Lights On Objective: Understand how to provide exceptional patient care from the time patients wake up from a sleep study until they walk out the door Case Study: Obstructive Sleep Apnea and Oral Appliance Objective: Be aware of potential recording dilemmas associated with a patients dental device and become proactive in developing sleep lab protocols for the use of oral appliances during sleep recordings Technical Corner: What Sleep Technologists Should Know About Oral Appliance Objective: Understand the basic differences in oral appliance designs and how oral appliance therapy is an effective treatment option for obstructive sleep apnea Manager's Desk: Effective Communication in Difficult Conversations Objective: Understand and utilize some strategies to manage difficult conversations with employees Ask Dr. Jim and Tracy: Mask Selection and Fit Objective: Understand how to engage patients and encourage their feedback when selecting a mask for a positive airway pressure (PAP) titration study

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aaSt CeC eValuatioN FormVOLUME 20 NUMBER 4To earn 1.5 hours of continuing education credit (CEC), carefully read four of the designated CEC articles from the list on the previous page. Then evaluate each article using the statements on this form. When completing this form be sure to include in the appropriate blanks the page number for each article that you read. After you have completed and signed this form you must fax it to the American Association of Sleep Technologists (AAST) national office at 630-737-9788, or have it postmarked, by the deadline of March 31, 2012, in order to receive credit. This service is free to AAST members. An A2Zzz subscriber who is not an AAST member is required to include payment of a $20 administrative fee with this form. Non-members who do not have an A2Zzz subscription must contact the AAST national office to become a subscriber. After the successful completion of this educational activity, a confirmation letter acknowledging that you have earned 1.50 AAST CECs will be sent six to eight weeks after the deadline to the email address that you have on file with the AAST. 5=Strongly Agree, 4=Agree, 3=Unsure, 2=Disagree, 1=Strongly Disagree 1. eDuCATiOnAl vAlue: I learned something new that was important. I verified some important information. I plan to discuss this information with colleagues. I plan to seek more information on this topic. My attitude about this topic changed in some way. This information is likely to impact my practice. 2. ReADAbiliTY FeeDbACK: I understood what the authors were trying to say. I was able to interpret the tables/figures (if applicable). Overall, the presentation of the article enhanced my ability to read and understand it. Article 1 Page# _______ Article 2 Page# _______ 54321 54321 54321 54321 54321 54321 54321 54321 54321 Article 3 Page# _______ 54321 54321 54321 54321 54321 54321 54321 54321 54321 Article 4 Page# ________ 54321 54321 54321 54321 54321 54321 54321 54321 54321

54321 54321 54321 54321 54321 54321 54321 54321 54321

plEaSE pRINt lEgIBlY oR tYpE

3. ADDiTiOnAl COmmenTS/FeeDbACK TO be uSeD bY The AAST CeC COmmiTTee: 4. COmmiTmenT TO ChAnGe:

What change(s), if any, do you plan to make in your practice as a result of reading any of these 4 articles?

5. STATemenT OF COmPleTiOn: I attest to having completed the AAST CEC activity (sign below).Signature Name (please print legibly) Address City Are you a member of the AAST? Yes No AAST Membership No: State Zip Date RPSGT Phone: ________/________/________Fax: ________/________/ ________ E-mail: RST

If you are not an AAST member, then are you an A2Zzz subscriber? Yes No

Check made payable to the AAST for $20 is enclosed orCardholder name (please print) Cardholder Address Card#:

Non-members who have a subscription must complete the following payment information:

Non-members who do not have an A2Zzzsubscription must contact the AAST national office to become a subscriber.

Charge $20 to (circle one): VISA / MasterCard / American ExpressSignature Expiration Date / /

You must fax your completed form to the AAST national office, or have it postmarked, by March 31, 2012 AAST National Office, 2510 North Frontage Road, Darien, IL 60561, Fax: (630) 737-9788


16

Free-ruNNiNg rHYtHm iN SigHteD peopleBy Regina Patrick, RST, RPSGTfree-running rhythm also called non-24-hour sleepwake syndrome or hypernychthemeral syndrome is a circadian rhythm sleep disorder in which the onset of a persons biological sleep phase occurs about an hour later each day. This results in the persons sleep phase slowly drifting around the clock over a period of several days. A person with a free-running rhythm has no difficulty in initiating sleep or maintaining wakefulness when following his or her biological rhythm. However, when attempting to adhere to a 24-hour schedule, the person with a free-running rhythm will experience alternating periods of insomnia (i.e., difficulty initiating and maintaining sleep) and excessive daytime sleepiness. This alternation occurs because sleep phase delays during the solar night result in the person having difficulty initiating sleep at a desired time, and sleep phase delays during the solar day result in the person having difficulty awakening and remaining awake at a desired time. A person with a freerunning rhythm typically has a circadian period that is greater than 24 hours. A free-running rhythm affects a greater number of males than females, and approximately 25 percent of sighted people with a free-running rhythm have a coexisting psychiatric disorder such as depression.1 Approximately 50 percent of blind people have a free-running rhythm,2 but it is rare in sighted people. As a result, a sighted person with symptoms of a freerunning rhythm may be misdiagnosed as having a psychiatric disorder or some other disorder. In 1971, Ann Elliott and colleagues were the first scientists to describe a free-running rhythm in a patient, who was a sighted male.3 He had difficulty trying to function socially on a 24-hour schedule. Elliott measured the rhythmicity of his sleep/wake cycles and the rise and fall of his body temperature while he was in an environment free of time cues. The results of these measurements revealed that the patient had a circadian period that was about 26 hours long. After the Elliott study, other researchers also noted a prolonged circadian period in people with a free-running rhythm, and by 1978 the term hypernychthemeral syndrome had been introduced to describe the phenomenon.4 (Hypernychthemeral is from three Greek words: hyper meaning above; nyx meaning night; and hemera meaning day.)

A

regiNa patriCK, rSt, rpSgtRegina Patrick, RST, RPSGT, has been in sleep field for more than 20 years and works as a sleep technologist at the Wolverine Sleep Disorders Center in Tecumseh, Mich.

The first attempt to treat a free-running rhythm in a patient was reported by Behrooz Kamgar-Parsi and colleagues in 1983.5 In their case report, the patient (a sighted male) developed sleep problems after undergoing several stressful life events. In an effort to improve his sleep, he began going to bed in the late evening and awakening late in the morning. With this regimen, he had hoped to increase his drowsiness to fall asleep more easily at night and to awaken more refreshed. However, the regimen resulted in delayed sleep phase syndrome (DSPS, a circadian rhythm sleep disorder in which the biological onset of a persons sleep and wake cycles are delayed). His sleep quality continued to deteriorate, and after several years he developed a free-running rhythm. He also had borderline hypothyroidism. (Hypothyroidism can cause vitamin B-12 deficiency6; some studies indicate that a low vitamin B-12 level may alter the circadian rhythm.6,7) The researchers prescribed the thyroid hormone thyroxine to improve his thyroid function. This was followed by treatment with flurazepam (to treat insomnia) and vitamin B-12 (to advance his circadian phases). After vitamin B-12 treatment, the patients sleep period advanced to a more desirable time. The patient was subsequently able to maintain a normal 24-hour sleep-wake cycle. An undiagnosed free-running rhythm may be mistaken for an endocrine disorder since it alters the rhythmicity of biological processes such as the production of endocrine hormones. For example, Dan Oren and colleagues noted multiple endocrine abnormalities in a patient whom they later diagnosed as having a free-running rhythm.8 The patient was a 37-year-old sighted man. Since his early teens, he had experienced difficulty going to sleep until late into the night. By the time he was in college, he had developed DSPS. At 28 years old, he initiated chronotherapy on his own in an effort to shift his sleep/wake cycles to a more desired time. For chronotherapy, a person progressively delays the bedtime later each day to shift the sleep phase to a more normal time; once the sleep phase is at the desired time, the person stops shifting the bedtime. In this case, however, once the patients sleep phase was at the desired time, he found that strictly adhering to the new schedule resulted in his struggling with daytime sleepiness indicating that his sleep phase was continuing to delay progressively every day. Through various tests, Oren found that the patient had a normal sensitivity to light and a normal vitamin B-12 level. However, he was exposed throughout the day to a very low level of light with an intensity of only 43 lux. (For comparison, 500 lux is the intensity of light on a bright sunny day.) He also had a small calcified pineal gland and asymmetric optic nerves. The extent to which the low level of light exposure and the small pineal gland (which produces melatonin) may have contributed to the patients impaired circadian rhythm was unclear to Oren. In two experimental conditions, Oren then measured the levels of the endocrine hormones melatonin, prolactin, luteinizing hormone, cortisol, testosterone, and thyroid-stimulating


17hormone (TSH). In the first condition, blood and urine samples were obtained to measure the level of melatonin when his biological night coincided with the solar night (i.e., when the patient was in phase). In the second experimental condition, blood samples were drawn when his biological night coincided with the solar day (i.e., when the patient was out of phase); his melatonin, thyroid-stimulating hormone (TSH), and testosterone levels were measured. The results showed that the patient had no detectable serum melatonin, although his urine had a lower-than-normal level of melatonin. When he was in phase, he lacked the normal surge of TSH production during sleep. When he was out of phase, he had an exaggerated TSH surge during sleep. Other endocrine hormones such as prolactin, luteinizing hormone (LH), and testosterone were at lower-than-normal levels. These abnormal findings indicated that the patient had an abnormal endocrine function. For treatment, the patient adhered to a strict sleep/wake schedule while undergoing bright light therapy (at 2500 lux) for two hours after awakening, and wearing dark goggles in the evening to minimize light exposure. After eight weeks of this regimen, the patients serum melatonin level returned to normal. Based on these findings, Oren suggests that a circadian rhythm sleep disorder such as a free-running rhythm should be part of a physicians differential diagnosis in a person presenting with abnormal levels of endocrine hormones. In children, symptoms of a free-running rhythm may be mistaken for a learning disorder (since excessive sleepiness may cause problems with concentration) or mistaken for a psychological or psychiatric disorder (because of the alternating periods of insomnia and excessive sleepiness). In 2001, Dagan and Ayalon reported their experience with a 14-year-old male who had been diagnosed as having depression, schizotypal personality disorder, and learning disabilities.9 The researchers assessed the patients sleep with an overnight polysomnographic study because the patient had excessive sleepiness. The polysomnographic results were negative for any sleep disorders. The patients circadian rhythm was assessed by wrist actigraphy, which involves wearing a watch-like instrument that records the frequency of a persons movements during wake and sleep. The results of wrist actigraphy showed he had a non-24-hour circadian period. Measurements of melatonin showed that his melatonin production was altered. They treated him with oral melatonin, which restored a normal sleep-wake schedule. A follow-up psychiatric evaluation found that he no longer suffered from any of his previous diagnoses. Delayed sleep phase syndrome may be a prodromal (i.e., forerunning) symptom in people who have a free-running rhythm since many people diagnosed with a free-running rhythm have struggled with DSPS for years before being diagnosed. Several researchers suspect that treating delayed sleep phase syndrome with chronotherapy later induces a free-running rhythm in some people. For example, it was after Orens patient had treated himself with chronotherapy that he noted that his sleep phase continued to delay about an hour later each day.8 In another report, Oren and his colleague Thomas Wehr described their experience with two patients who developed a free-running rhythm after undergoing chronotherapy.10 Angela McArthur and colleagues described a patient who had treated himself with chronotherapy for five years for DSPS.3 Behaviorally, he was able to maintain a consistent sleep/wake schedule. However, alternating periods of severe insomnia and excessive daytime sleepiness indicated that his sleep/wake phases were not entrained (i.e., occurring in association with external cues such as light and darkness) and that his symptoms were the consequence of a free-running rhythm. How to best treat a free-running rhythm in a sighted person has not been definitively determined since most reports in the medical literature are case reports involving few people. For example, the finding that vitamin B-12 improves entrainment in some people with a free-running rhythm is based on two case reports,6,7 and no research has focused on its efficacy in entrainment.2 However, the results of various reports indicate that bright light therapy and the administration of melatonin effectively improve entrainment in some people with a free-running rhythm. Mark Brown and colleagues prescribed melatonin to advance the sleep phase in a 67-year-old sighted man who had a free-running rhythm that was coexistent with severe depression, anxiety, obsessive-compulsive disorder (OCD), and agoraphobia.11 The patient described having had problems for 22 years with sleep cycling, by which he meant that his sleep was progressively delayed by about one-half hour each day (i.e., free-running rhythm). For treatment, Brown prescribed melatonin (to advance the sleep phase), which the patient took one hour before going to bed. Each week, he took melatonin one-half hour earlier. Once the sleep phase was advanced to the desired time, he continued to take the dose of melatonin at the same time. He also underwent bright light therapy for one hour just after awakening to advance his wake phase. By maintaining this regimen, he was able to maintain a stable sleep/wake schedule. Angela McArthur and colleagues found that their patient was less sensitive than normal to the melatonin-suppressant effect of bright light.3 For example, at 2500 lux, his melatonin production was only reduced by 78 percent after two hours; in most people, melatonin production would be reduced by this much in one hour. Rather than using bright light therapy to shift the patients sleep/wake phases, McArthur prescribed melatonin. The patient took the medication daily, and by four weeks of treatment, his sleep/wake rhythms had stabilized. A physician may not think to assess a patient presenting with abnormal endocrine function or alternating periods of insomnia and excessive sleepiness for a free-running rhythm since it is rare in sighted people. The physician may instead treat the patient for another disorder such as depression, which may worsen the free-running rhythm. For example, certain serotonin reuptake inhibitor drugs used to treat depression may aggravate the free-running rhythm by decreasing a persons response to light cues.3 An untreated free-running rhythm can be debilitating for a sufferer since alternating periods of insomnia and sleepiness hinder the persons ability to effectively function socially, at work, or at school. Therefore, recognizing symptoms of a free-running rhythm in a sighted person may prevent the person from being misdiagnosed and suffering the consequences of improper treatment.

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reFereNCeS1. Sack RL, Auckley D, Auger RR, et al. Circadian rhythm sleep disorders: part II, advanced sleep phase disorder, delayed sleep phase disorder, free-running disorder, and irregular sleep-wake rhythm. Sleep. 2007;30(11):14841501. Morgenthaler TI, Lee-Chiong T, Alessi C, et al. Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders. Sleep. 2007;30(11):1445-1459. McArthur AJ, Lewy AJ, Sack RL. Non-24-hour sleepwake syndrome in a sighted man: circadian rhythm studies and efficacy of melatonin treatment. Sleep. Sep 1996;19(7):544-553. Kokkoris CP, Weitzman ED, Pollak CP, et al. Long-term ambulatory temperature monitoring in a subject with a hypernychthemeral sleep--wake cycle disturbance. Sleep. Winter 1978;1(2):177-190. Kamgar-Parsi B, Wehr TA, Gillin JC. Successful treatment of human non-24-hour sleep-wake syndrome. Sleep. 1983;6(3):257-264. Ohta T, Ando K, Iwata T, et al. Treatment of persistent sleep-wake schedule disorders in adolescents with methylcobalamin (vitamin B12). Sleep. Oct 1991;14(5):414-418. 7. Okawa M, Mishima K, Nanami T, et al. Vitamin B12 treatment for sleep-wake rhythm disorders. Sleep. 1990 Feb;13(1):15-23. Oren DA, Giesen HA, Wehr TA. Restoration of detectable melatonin after entrainment to a 24-hour schedule in a free-running man. Psychoneuroendocrinology. 1997 Jan;22(1):39-52. Dagan Y, Ayalon L. Case study: psychiatric misdiagnosis of non-24-hours sleep-wake schedule disorder resolved by melatonin. J Am Acad Child Adolesc Psychiatry. Dec 2005;44(12):1271-1275.

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10. Oren DA, Wehr TA. Hypernyctohemeral syndrome after chronotherapy for delayed sleep phase syndrome. N Engl J Med 1992 Dec 10;327:1762. 11. Brown MA, Quan SF, Eichling PS. Circadian rhythm sleep disorder, free-running type in a sighted male with severe depression, anxiety, and agoraphobia. J Clin Sleep Med Feb 15 2011;7(1):93-94.

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patieNt Care praCtiCeS FolloWiNg ligHtS oNBy Anglee Leviner, RPSGTatient care is something that begins for the night shift technologist when the patient arrives in the sleep center, and ends when the patient walks out the door. A set of standards is integral to the thorough completion of patient care and satisfaction. While specific policies and procedures for morning routine vary from facility to facility, there remain certain staples in accomplishing an exemplary procedure following lights on. There are so many extra efforts that could be counted toward the goal of patient care in the morning. The focus is on pivotal tasks that serve patient needs and safety, such as: cleaning and removing the wires, being mindful of patient alertness, and appropriately as well as fully answering all patient concerns or questions before they exit the sleep center. Some procedures are active and directly relate to the patient, while others are passive, requiring a mindful and informed technologist to watch out for the patients best interests. All of the following suggested patient care practices must be implemented simultaneously for the best results.

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not accept this as a necessary step in the morning routine. It is true that leaving paste on a patients head and face may not cause him or her direct harm. Assuming that all patients are capable of removing all remnants of the residue is dangerous, and will lead to some very irate patients complaining to anyone who will listen. Different brands of paste have various warnings and directions in reference to leaving the paste on the patient. Most indicate directions for removal, specifying to remove the paste during unhook and clean up procedures.2 All brands of paste list the importance of not leaving any paste within reach of the patient, and this does include his or her own body. Judging the individual competency of each patient can be very difficult. One cannot be certain that a patient will not get paste in his or her eyes, or decide to taste it. For specific instructions and warning about any paste, one should consult the Material Safety Data Sheets (MSDS) that correspond to each product. When in doubt for the patients safety, it is best to err on the side of caution, rather than risk the health and safety of the patient.

ligHtS oN, NoW WHat?

Gliding past the procedures for calibrations that are specific to each sleep center, let us skip straight to the moment when you walk into the patients room to turn the lights on. It is always considerate to warn your patients before flipping the lights on in the patient room. Ones pupils are dilated after sleeping in a dark room all night, and the shock of bright shining lights is not a pleasant surprise. Consideration plays a large part in the segment of the study that follows lights on. Now the patient is prepared to sit up or get up in preparation for equipment removal. Small talk, and how one addresses the patient at these times, is entirely a personal preference. The patient should be forewarned anytime a lead that may cause discomfort or pain is being removed. There are several products that aid in painless removal of tape by first dissolving the adhesive agent bonding to the patient. If the lab does not stock any specific products for adhesive removal, dabbing isopropyl alcohol on the tape will go a long way in preventing skin damage. Ripping without following these procedures can cause damage to the skin, especially in older patients. Stripping of the skin can occur if you do not adhere to proper removal techniques.1 Once a patient is free of any equipment, it is time to remove all residue left behind by the paste or collodion on the patients scalp and face. This is a topic of contention for many, as some do

FielDiNg patieNt QueStioNS

aNglee leViNer, rpSgtAnglee Leviner, RPSGT, has been in the sleep field since 2006 and is a senior acquisitions technologist for SleepWorks LLC in Statesville, N.C.

This essential process in the morning routine can be fulfilled during any or all of the phases that encompass the lights on procedure. Be prepared to converse during the lead and paste removal, after removal, or after the patient is dressed and prepared to leave the lab. Many times patients are hesitant to speak up and ask questions; therefore, it becomes the technologists duty to open up the interactions and to make asking questions easier for the more timid patients. As will be discussed soon, patients may be disoriented when they first wake and while the equipment is being removed. Let patients know that once they complete their own morning routine, you will be available to field any questions or concerns they may have. After patients have been given time to reflect on the study and contemplate the future, it is likely they will have thought of new questions. Once it is certain that the patient has had every opportunity to satisfy his or her curiosity, it is important to understand how best to respond to these questions. The most important factor when addressing the concerns of patients is to be positive; do not alarm the patient. Technologists should assume that their patients know nothing about sleep disorders when answering their questions. Be sure that you do not alarm the patient when discussing their diagnosis or treatment. What a technologist is allowed to share with the patient in the morning varies from state to state. A recent proposal would allow patients the right to be informed of their results the morning following a study.3 Of course, if a lab does not create reports in the morning, this law will not apply. The technologist would not have to share his or her observations with the patient; only the report generated from a study would fall under the new rule proposed by the Centers for Medicare and Medicaid services (CMS). Nearly half the states in America do not have a standing law in regard to direct results given to patients by the lab. Even within these states, technologists should first adhere to the policies set forth by the referring physician or sleep center management.


21There are several reasons why labs may prohibit results and data from being shared with the patient in the morning. The patient may not understand the results and may become alarmed. Also, the technologist may conflict with the physicians final decision. Quite simply, the technologist may be incorrect. This misinformation can produce a confused and frustrated patient. A physician or lab will have a hard time following up for treatment and compliance with a patient who has been misinformed about their results. Rather than being a hindrance, restricting the discussion of results with the patient in the morning is actually a way to protect the technologist. Sleep inertia poses a real threat to patient safety and sleep center liability. Sleep inertia is a transitional state of lowered arousal occurring immediately after awakening from sleep. It produces a temporary diminution in all subsequent tasks.4 This condition can last anywhere from one minute to four hours, but usually lasts only 15 to 30 minutes. It is in the best interests of the patient for the technologist to be aware of ways to minimize the severity and likelihood of sleep inertia onset. How long a patient has slept, and which stage they are woken from, play a large part in the potential severity of sleep inertia. Limiting the chances of sleep inertia and identifying patients who are suffering from cognitive restrictions are crucial to patient safety. Sleep inertia can cause impairment of motor skills and cognitive functions, specifically the ability to drive safely home. The first efforts that can be taken to avoid this state of debilitating awareness are to take great care in not waking patients from high-risk stages of sleep. Stage N3 creates the highest risk of sleep inertia.5 When a patient has a relatively normal night of sleep, this is not problematic since N3 subsides in the last third of the sleep cycle. However, if a patient took longer than normal to fall asleep, then N3 is a possibility; careful observation will be required if the technologist must wake a patient in this stage. Following N3, rapid eye movement (REM) sleep becomes the next high-risk stage of sleep. Technologists should try to avoid waking patients from REM sleep. In order to ensure patient safety, it is beneficial to insist that patients remain in the lab for a minimum of 30 minutes after lights on before they are allowed to drive. A study published in 2010 suggests that coffee is not a solution for patients who may be at risk while driving. The researchers found that caffeine did not increase the alertness of any group of participants.6 Research published in 2006 emphasized the danger of sleep inertia. The researchers found that cognitive performance immediately after waking from eight hours of sleep was worse than during a period of 26 hours of sleep deprivation.7 Impairments were most severe within the first three minutes of awakening. Patients typically seen in a sleep center are likely to be sleep deprived and to possess a high sleep debt. Sleep deprivation exacerbates sleep inertia, which can lead to microsleeps. These brief episodes of attention loss are associated with actions such as blank stares, head snapping, and prolonged eye closure. Microsleeps may occur when a person is fatigued and making efforts to perform monotonous tasks such as driving. If a patient shows signs of microsleeps, it is imperative to retain him or her in the sleep center until full cognitive function can be confirmed. A patient can have microsleeps and be completely unaware, with eyes remaining open through the event. A patient who has a microsleep while driving will be unable to notice or respond to exterior information such as a red light or a sharp curve. It is up to the sleep technologist to thoroughly analyze patients for cognitive responses after lights on. If a patient shows signs of lethargy, confusion or disorientation, or is unresponsive, then it may be necessary to test his or her motor skills and cognitive responses. Test the patients working memory by stating something for the patient to remember and then asking him or her to say it back to you after completing a simple task. Next, test the patients hand-eye coordination. Any tests that are used to discern intoxication should be applicable when attempting to confirm sleep inertia. In some cases a patient may request to leave against the advice of sleep center staff who are concerned about the patients capacity to drive. In this situation, ask the patient to sign an American Medical Association (AMA) release form for refusal of care against medical advice. A patient cannot be forced to stay in the sleep center against his or her will. Documenting an attempt to retain the patient is an important step to protect the sleep centers liability should a motor vehicle accident take place.

liabilitY aND Sleep iNertia

CoNCluSioN

Consideration and careful observation are the keys to ensure patient safety, which is the goal of the post lights on period in the sleep center. Methods can vary, as long as patient care remains the motivating factor of the morning routine. Combining careful removal of leads, removing paste, and answering questions both respectfully as well as attentively should ensure complete patient satisfaction. How the study ends is what will be fresh in the patients mind when leaving the sleep center. Hopefully the patient will leave the facility satisfied, awake, clean, and safe to drive.

reFereNCeS1.

3M. Reducing the risk of superficial skin damage related to adhesive use [Internet]. c2001. Available from: http:// tinyurl.com/d232h6t Elefix (Paste for EEG) Operators Manual. Z-401CE, Z-181JE. Centers for Medicare & Medicaid Services. CLIA program and HIPAA privacy rule; patients access to test reports. Federal Register. 2011 Sep 14;76(178):56712-56724.

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Scheer FA, Shea TJ, Hilton MF, Shea SA. An endogenous circadian rhythm in sleep inertia results in greatest cognitive impairment upon awakening during the biological night. J Biol Rhythms. 2008 Aug;23(4):353-61. Mahowald M. Confusional arousals and sleep inertia. Stanford Sleep Epidemio J [Internet]. 2011;IV(1). Available from: http://www.sleepepidemiojournal.org/Past%20Issues/ IssueEleven.htm Rogers PJ, Hohoff C, Heatherley SV, et al. Association of the anxiogenic and alerting effects of caffeine with ADORA2A and ADORA1 polymorphisms and habitual level of caffeine consumption. Neuropsychopharmacology. 2010 Aug;35(9):1973-83. Epub 2010 Jun 2. Wertz AT, Ronda JM, Czeisler CA, Wright KP Jr. Effects of sleep inertia on cognition. JAMA. '06 Jan 11;295(2):163-4. Available : http://jama.ama-assn.org/content/295/2/163.long

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CaSe StuDY: obStruCtiVe Sleep apNea aND oral appliaNCeBy Joanne hebding, RPSGT

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he patient is a 50-year-old male who presented to his primary care physician in 2011 for evaluation and advice concerning obstructive sleep apnea (OSA). The patient was diagnosed by polysomnography 15 years ago with OSA. No previous positive airway pressure (PAP) titration study was done. The patient underwent turbinate reduction surgery last year and stated he had significant improvement in his sleep apnea. Unfortunately, no follow-up sleep study was performed to verify his statement. He stated that he was experiencing bruxism and went to see a local dentist, who fitted him with an oral appliance. The patient used the prescribed oral appliance for approximately eight nights and was told by his spouse that he was not snoring as much as before. However, he related to his primary care physician that he was experiencing daytime sleepiness and felt unrefreshed upon awakening. He reported waking himself up with loud snoring and gasping. The patient reported feeling drowsy while driving. He said that he goes to bed at 10 p.m. and falls asleep within a couple of minutes. He gets up once during the night for nocturia, then arises in the morning at about 4:30 a.m., estimating that he gets five to six hours of sleep per night. The patient also has been diagnosed with hypertension, hyperlipidemia and obesity, with a body mass index of 31.38. Physical examination was unremarkable except for the uvulopalatopharyngoplasty (UPPP) scar noted on oropharyngeal examination. The patient had an Epworth Sleepiness Scale score of 15 (NL

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