From time to time BRPT invites a "guest blogger" to contribute a short article in this space. The opinions, representations and statements made within a "guest" article are those of the author and should not be construed as statements made on behalf of BRPT. Copyright remains with the author.
By Dr. Vikas Jain
We’re all aware of the changing landscape in sleep medicine. I’ve learned in traveling to the annual sleep meeting, as well as speaking with technologists both locally and nationally, that many individuals are concerned with what the future of sleep medicine holds. Although the landscape is changing, I believe we are well equipped to tackle the challenges – and opportunities – that lie ahead. We do, however, first need to consider what services and technologies are infringing upon our current standard of care and delivery.
New Technologies Change The Way We Work
Over utilization of sleep studies has contributed to putting sleep medicine on the radar. Surveys of sleep centers across the country all show the same trends: reduction in sleep center bed and patient volume growth, and an increase in out of center sleep testing (OCST) utilization. But more important than merely the discussion of OCST versus in-lab testing, is the discussion of how the role of the sleep technologist may be impacted. When considering experience, Nigro et. al. showed that an individual with very little polysomnography experience was able to score as well as a physician with several years experience when correcting auto-scored data. Furthermore, a study by Malhotra et. al. in the 2013 Sleep Journal displayed that the use of an automated polysomnography scoring system yielded results that were similar to those obtained by experienced technologists. The utility of PAP titration studies are also being evaluated as some insurance companies are opting for patients to be titrated using AutoCPAP’s over in-lab titration. In the age of
wearable technology, we are also seeing new technologies emerging that track and monitor sleep which may make the use of actigraphy obsolete. With all of these disruptive innovations impacting our field, I can understand why many sleep professionals are wary of the future.
Moving Towards A Management/Long-Term Care Model
I believe the future remains very bright for our field. We don’t have to shift our focus away from Obstructive Sleep Apnea, (OSA) but should make efforts to expand our focus to include other highly prevalent sleep disorders such as Insomnia and Restless Legs Syndrome. As the obesity epidemic in America continues to grow, the incidence of new sleep apnea cases is likely to continue to increase as well. These changes, along with more emphasis being placed on clinical outcomes, are shifting our care paradigm from diagnostic/short-term care to a management/long-term care model. This change in care delivery is where I believe the greatest opportunity for sleep technologists lie.
We can expect to see: a reduction in overnight studies/night techs; increase acuity in individuals requiring in-lab overnight studies due to comorbidities; an increased demand for OCST; and, an increased demand for treating sleep disorders other than OSA.
Sleep Technologists Will Need A Varied Skill Set And Leadership Skills
Given these changes, we will need technologists who have broader skill sets. Technologists will require knowledge of more advanced PAP modalities such as AVAPS and ASV given the increased acuity of in-lab polysomnography patients. They may need knowledge of a variety of PSG montages that may be used for evaluating patients with disorders such as seizures or parasomnias. In addition, given the increasing incidence and prevalence of OSA, knowledge of alternative therapies for the treatment of OSA will prove useful. Finally, given that there are approximately only 7,500 sleep physicians in the United States, we will need more “sleep clinicians” to help in the management of our patients. We’ll need sleep technologists with leadership skills to assist in patient/community education, protocol development within hospital systems, and in research/population health. There’s tremendous opportunity here!
One path that can help sleep technologists build these skills is the BRPT’s Clinical Sleep Educator certificate program. In addition to the CSE program, I would strongly urge sleep technologists to consider pursuing the new Certification In Clinical Sleep Health (CCSH) credential. This is an advanced credential that establishes a common skill and knowledge base for clinical sleep health professionals. It provides recognition that an individual has knowledge of four domains: Sleep Over the Lifespan, Clinical Evaluation and Management, Patient/Family Communication and Education, and finally Program Maintenance and Administration. This type of knowledge is essential in the formation of a full service sleep disorders center. In practice, I have found that working with a sleep technologist with this skill set has improved sleep clinic efficiency, has helped to increase reimbursement for my practice, improved outcome measures such as PAP compliance, and overall provided true value to both referring providers as well as patients.
There is no denying that the landscape in sleep medicine is changing. Yet no one understands and has a knowledge of sleep better than those of us who are intimately involved in sleep medicine. So let’s put worry and apprehension aside and seize the current opportunities available to expand our field of knowledge. It’s time for all of us to take an active role in creating the future of sleep medicine!
Dr. Jain is a board certified sleep medicine physician who practices full time adult and pediatric sleep medicine in Oklahoma City, OK. He completed his fellowship at the Stanford Sleep Disorders Center in 2012.
Thursday, October 16, 2014
Wednesday, March 19, 2014
The Nexus Between Oral Appliance Therapy and Treating Certain Sleep Disorders
From time to time BRPT invites a "guest blogger" to contribute a short article in this space. The opinions, representations and statements made within a "guest" article are those of the author and should not be construed as statements made on behalf of BRPT. Copyright remains with the author.
By Victor Woodlief, DMD
When it comes to my work as a dentist, there are three things I’m really passionate about: the absolute need to treat each patient as an individual; the need for collaboration with other healthcare practitioners; and, keeping an open mind in this evolving health care arena.
In my practice, I’ve had the great pleasure of collaborating with terrific sleep medicine doctors and sleep technologists when it comes to treating mild to moderate obstructive sleep apnea (OSA). And we’ve really seen first-hand how oral appliances can be a very successful front-line treatment for snoring and OSA. The plastic device fits in the mouth during sleep like a sports mouth guard or orthodontic retainer, helping to prevent the collapse of the tongue and soft tissues in the back of the throat, keeping the airway open during sleep and promoting adequate air intake. And, oral appliances may be used alone or in combination with other treatments for sleep-related breathing disorders, such as weight management, surgery or CPAP.
An Overview Of The Important Steps To Take When Considering Oral Appliance Therapy
Oral appliance therapy involves the selection, fitting and use of a specially designed oral appliance that maintains an open, unobstructed airway in the throat when worn during sleep. In my experience, custom-made oral appliances are proven to be more effective than over-the-counter devices, which are not recommended as a screening tool or a therapeutic option.
Dentists with training in oral appliance therapy are familiar with the various designs of appliances and can help determine which is best suited for your patient’s specific needs. A board certified sleep medicine physician must first provide a diagnosis and recommend the most effective treatment approach. A dental sleep medicine specialist will then provide treatment and follow-up.
The initial evaluation phase of oral appliance therapy includes an examination and evaluation to determine the most appropriate oral appliance, fitting, maximizing adaptation of the appliance, and the function.
Of course, ongoing care including short- and long-term follow-up, is an essential step in the treatment of snoring and OSA with oral appliance therapy. Follow-up care with a sleep study serves to assess the treatment of your patient’s sleep disorder, the condition of your patient’s appliance, and your patient’s physical response to the appliance making sure it’s comfortable and effective.
Advantages of Oral Appliance Therapy
I’ve seen many advantages to using oral appliances, the least of which is they are easy and comfortable to wear. In fact, most patients find it only takes a couple of weeks to become acclimated to wearing the appliance. In addition, they’re small and convenient making them easy to carry when traveling – I have patients who don’t miss a beat when going camping or hunting! Lastly, treatment with oral appliances is reversible and non-invasive.
Understanding The Different Types Of Oral Appliances
With so many different oral appliances available, selection of a specific appliance may appear somewhat overwhelming. Oral appliances can be classified by mode of action or design variation. And, it helps to know that nearly all appliances fall into one of two categories: Mandibular Advancement Device (MAD) and Tongue Retaining Device (TRD).
Mandibular advancement devices reposition and maintain the lower jaw in a protruded position during sleep. The device serves to open the airway by indirectly pulling the tongue forward, stimulating activity of the muscles in the tongue and making it more rigid. The device also holds the lower jaw and other structures in a stable position to prevent the mouth from opening.
Tongue retaining devices hold the tongue in a forward position using a suction bulb. When the tongue is in a forward position, it serves to keep the back of the tongue from collapsing during sleep and obstructing the airway in the throat.
In short, there is a time and place for treating patients with sleep disorders using oral appliance therapy and in doing so I’ve seen terrific results and have very much enjoyed working with other health care practitioners. It’s exhilarating to be a part of a larger network that communicates, collaborates and comes together to provide high quality individual patient care.
By Victor Woodlief, DMD
When it comes to my work as a dentist, there are three things I’m really passionate about: the absolute need to treat each patient as an individual; the need for collaboration with other healthcare practitioners; and, keeping an open mind in this evolving health care arena.
In my practice, I’ve had the great pleasure of collaborating with terrific sleep medicine doctors and sleep technologists when it comes to treating mild to moderate obstructive sleep apnea (OSA). And we’ve really seen first-hand how oral appliances can be a very successful front-line treatment for snoring and OSA. The plastic device fits in the mouth during sleep like a sports mouth guard or orthodontic retainer, helping to prevent the collapse of the tongue and soft tissues in the back of the throat, keeping the airway open during sleep and promoting adequate air intake. And, oral appliances may be used alone or in combination with other treatments for sleep-related breathing disorders, such as weight management, surgery or CPAP.
An Overview Of The Important Steps To Take When Considering Oral Appliance Therapy
Oral appliance therapy involves the selection, fitting and use of a specially designed oral appliance that maintains an open, unobstructed airway in the throat when worn during sleep. In my experience, custom-made oral appliances are proven to be more effective than over-the-counter devices, which are not recommended as a screening tool or a therapeutic option.
Dentists with training in oral appliance therapy are familiar with the various designs of appliances and can help determine which is best suited for your patient’s specific needs. A board certified sleep medicine physician must first provide a diagnosis and recommend the most effective treatment approach. A dental sleep medicine specialist will then provide treatment and follow-up.
The initial evaluation phase of oral appliance therapy includes an examination and evaluation to determine the most appropriate oral appliance, fitting, maximizing adaptation of the appliance, and the function.
Of course, ongoing care including short- and long-term follow-up, is an essential step in the treatment of snoring and OSA with oral appliance therapy. Follow-up care with a sleep study serves to assess the treatment of your patient’s sleep disorder, the condition of your patient’s appliance, and your patient’s physical response to the appliance making sure it’s comfortable and effective.
Advantages of Oral Appliance Therapy
I’ve seen many advantages to using oral appliances, the least of which is they are easy and comfortable to wear. In fact, most patients find it only takes a couple of weeks to become acclimated to wearing the appliance. In addition, they’re small and convenient making them easy to carry when traveling – I have patients who don’t miss a beat when going camping or hunting! Lastly, treatment with oral appliances is reversible and non-invasive.
Understanding The Different Types Of Oral Appliances
With so many different oral appliances available, selection of a specific appliance may appear somewhat overwhelming. Oral appliances can be classified by mode of action or design variation. And, it helps to know that nearly all appliances fall into one of two categories: Mandibular Advancement Device (MAD) and Tongue Retaining Device (TRD).
Mandibular advancement devices reposition and maintain the lower jaw in a protruded position during sleep. The device serves to open the airway by indirectly pulling the tongue forward, stimulating activity of the muscles in the tongue and making it more rigid. The device also holds the lower jaw and other structures in a stable position to prevent the mouth from opening.
Tongue retaining devices hold the tongue in a forward position using a suction bulb. When the tongue is in a forward position, it serves to keep the back of the tongue from collapsing during sleep and obstructing the airway in the throat.
In short, there is a time and place for treating patients with sleep disorders using oral appliance therapy and in doing so I’ve seen terrific results and have very much enjoyed working with other health care practitioners. It’s exhilarating to be a part of a larger network that communicates, collaborates and comes together to provide high quality individual patient care.
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