Which patients may need sleep studies?
- Patients who report loud snoring, are overweight, grind their teeth at night, experience persistent daytime tiredness or morning headaches, have a larger neck circumference, higher BMI, or other comorbidities need a polysomnogram (PSG) or overnight sleep study in one of our five locations in Northern Virginia. Our centers offer all the comforts of home and are more similar to a higher end boutique hotel than a clinical facility.
- Patients with sleep apnea may require a second PSG for CPAP initiation
- Patients with severe sleepiness or unrefreshing sleep, who are not chronically sleep deprived and who have no other apparent cause of persistent sleepiness usually need a PSG to determine whether they have sleep apnea or another type of sleep disorder. Additionally, such patients typically need a Multiple Sleep Latency Test (MSLT) to quantify their degree of sleepiness and to seek sleep-onset REM periods as may occur in narcolepsy patients.
- Patients with insomnia usually need diagnostic testing if the insomnia has persisted despite more than 6 months of treatment, or if they snore or report restless sleep which may suggest underlying sleep apnea or periodic limb movement disorder as a significant contributing factor in disrupted sleep.
Which specialized patient populations who suffer from chronic disease states or conditions are recommended for sleep studies to rule in or out OSA?
Bariatric surgery patients
- Before bariatric surgery patients need testing for possible sleep apnea. About 50-80% of candidates for bariatric surgery have significant sleep apnea, and screening questionnaires are not adequate to determine which patients should be tested.
Chronic pain management patients
- Chronic pain management patients, as narcotics and in particular opioids, have several effects on respiratory physiology, which are more pronounced during sleep. They decrease central respiratory patterns, respiratory rate, and tidal volume. They also increase airway resistance and decrease the patency of the upper airways. This may lead to ineffective ventilation and upper airway obstruction in susceptible individuals. The presence of CSA and OSA is higher with these patients than the general population.
Patients with Type 2 diabetes or hypertension
- Overwhelming clinical evidence has shown that patients suffering from two very common illnesses – Type 2 diabetes and hypertension – are at much higher risk for obstructive sleep apnea (OSA), a dangerous condition characterized by episodes of complete or partial airway obstruction during sleep. Research also has shown that treating sleep apnea can help in the management of these two disorders.
- The link between obstructive sleep apnea (OSA) and cardiovascular disease is increasing in awareness amongst researchers and clinicians worldwide Evidence has established that sleep apnea is associated with hypertension, atrial fibrillation (AFib), coronary artery disease, congestive heart failure and stroke. Multiple sleep disorders have a direct adverse effect on the cardiovascular system and a team approach between the patient’s provider and a board-certified sleep medicine physician is imperative to ensure an optimal outcome for the patient.
- The incidence of OSA in patients with certain neurological conditions such as Parkinsonism, myotonic dystrophy, and myasthenia gravis is higher than in the general population, primarily due to the impairment of the nerves controlling the muscles of the upper airway. Neurological disorders and OSA can coexist and, potentially, exacerbate each other.
Pulmonary disease patients
- Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) represent two of the most prevalent chronic respiratory disorders in clinical practice and cardiovascular diseases are a common co-morbidity in each disorder. While COPD patients are prone to poor sleep quality, in addition to disturbances in ventilation and gas exchange during sleep, the coexistence of OSA and COPD is also common, and is referred to as the overlap syndrome. Overlap patients develop more pronounced nocturnal oxygen desaturation than COPD or obstructive sleep apnea syndrome (OSAS) alone, which predisposes to pulmonary hypertension and more severe cardiovascular disease.
Does every snoring patient need a PSG sleep study?
There is no other good way to separate people with severe sleep apnea from those with simple snoring. For example, some patients with mild sleep apnea on the PSG turn out to have very severe sleepiness that is relieved by CPAP therapy. Other people, who aren’t bothered much by their snoring, turn out to have severe apnea in sleep; and left untreated those patients, have higher vascular disease risk. The sleep research community is working on new diagnostic options to help us in this area, but sleep research is relatively new, and we have a long way to go to catch up with the base of knowledge in heart or lung medicine. Snoring patients who are not sleepy, and who do not have high cardiovascular risk profile might be treated for snoring without undergoing overnight testing.
Will my patients need a consultation with one of your sleep medicine physicians?
Yes, a sleep consultation is recommended, and most often required by insurance companies. Our board-certified sleep medicine physician practice is solely focused on the diagnosis and treatment of sleep disorders. While our physicians are board-certified in areas such as neurology, psychiatry, and internal medicine, 100-percent of their practice is devoted to sleep health and as communication is key, we work with our referring providers to provide a multi-disciplinary care approach in the coordination of their patient’s care.
Which sleep test should I order?
- Our board-certified sleep medicine physicians will often determine the best sleep test for your patient during the consultation. Typically, polysomnography (PSG) alone is adequate to assess most people for possible sleep apnea and to rule out other sleep disorders.
- The Multiple Sleep Latency Testing (MSLT) is used selectively to further quantify sleepiness and to distinguish narcolepsy from idiopathic hypersomnolence.
- A split-night study includes an initial diagnostic PSG, and then CPAP is started if significant sleep apnea is clearly present. It is especially useful after the physician has thoroughly discussed sleep treatment options with the patient, and when the patient has a good idea of the nature, and treatment value of CPAP. A split-night study, when successful, allows diagnosis of sleep apnea and treatment with CPAP during a single night. During a split-night study the technologist is instructed to perform a standard diagnostic PSG for at least two hours of sleep.
The American Academy of Sleep Medicine’s Indications for a split-night PAP titration study is as follows:
- A split-night PAP titration is indicated for patients who are diagnosed with severe OSA, which is defined as an AHI of at least 40 documented during a minimum of two (2) hours of diagnostic PSG. A split-night study may be considered in a patient with an AHI of 20 to 40, based on clinical judgment.
- Patients may be referred for a split-night PAP titration when there is a strong clinical suspicion of severe OSA after an initial clinical evaluation, or a split-night study may be undertaken due to severe OSA seen during the PSG that is accompanied by significant oxygen desaturation and/or cardiac arrhythmias.
A split-night protocol may halve the cost of diagnosis and treatment initiation for sleep apnea patients, but it requires that the technologist make the initial diagnosis based on an incomplete recording. Since apneic episodes often are more frequent or more severe during REM sleep, and since REM sleep usually predominates in the latter half of the night, a two-hour initial baseline PSG may underestimate significantly the baseline severity of apnea. The effects of body position on breathing may be missed during an abbreviated diagnostic study, and there may be insufficient time during an abbreviated diagnostic study, and there may be insufficient time during CPAP titration to be certain that breathing has been corrected in all positions and sleep stages. Despite these limitation split-night studies are a valuable tool to help reduce costs and inconvenience.
The following are situations when CPAP may not be started, even though a split-night study was ordered:
- Some patients may sleep poorly in the sleep center, and they may not complete two hours of sleep until three, four, or more hours have elapsed. CPAP will not be started for those patients since there is not time enough left to allow an accurate determination of the best CPAP treatment pressure.
- Some patients have mild sleep apnea by PSG criteria, but still may benefit from CPAP treatment. We do not start CPAP if the AHI is below 20-40/hour during the baseline, even if they have very frequent milder events of sleep disordered breathing. This is partly because those patients may choose alternate treatment such as dental appliance therapy, and partly because those patients a half-night study may miss the most severe apneic episodes occurring later in the night. Some patients have very frequent episodes of sleep-disordered breathing, but each even is mild. (See below the discussion about respiratory effort-related arousals, or RERAs.) Patients with a severely abnormal RDI but normal AHI may have severe sleepiness, and they often benefit from therapy for sleep apnea, but they may not qualify for Medicare coverage for treatment.
Aggressive Split-Night Protocol
- Depending on the patient an aggressive split-night study may be recommended, In that case, CPAP is started after about 2 hours of sleep if the RDI is 15/hour or higher, even if all obstructive events are very mild. CPAP also may be started after 30 minutes of baseline study if there is very severe sleep apnea.
In-home sleep studies
- CSCC is always at the forefront of new methods, including those that make life a bit easier for our patients. With that in mind, we now offer portable monitoring equipment for use in the home. Home sleep tests are intended specifically to evaluate patients without co-morbidities (neurologic, cardiac, or significant pulmonary disorders) who are considered to be moderate to high risk for sleep apnea.
What is the difference between the AHI and the RDI in sleep apnea?
Abnormal breathing is summarized by either an Apnea Hypopnea Index (AHI) or a Respiratory Disturbance Index (RDI). The terms are very similar but have slightly different definitions. Your AHI is the average number of apneas and hypopneas per hour of sleep and is calculated by taking the total number of apneas and hypopneas and dividing it by the number of hours of sleep. Your RDI is the average number of abnormal breathing events that occurred per hour of sleep, so it may include abnormal breathing events other than apneas and hypopneas such as Respiratory Effort-Related Arousals (RERAs). The higher your patient’s RDI or AHIm the more severe the disorder.
Typically we recommend treating an AHI over 5 or 10, which is considered mild sleep apnea. If you think about it, 10 breathing events per hour means that you are waking up up every six minutes – it’s like sleeping with a snooze alarm all night. There is little to lose and everything to gain.
What is complex sleep apnea?
Complex sleep apnea is diagnosed when there are elements of obstructive and central sleep apnea at baseline, or when central apneas appear during CPAP titration. Complex sleep apnea most often is idiopathic, but occurs in high frequency among patients who are treated with chronic narcotics, or those who have brain dysfunction or congestive heart failure. Patients with central sleep apnea may respond best to treatment with multiple modalities, including CPAP or Bi-PAP, supplemental oxygen, and hypnotic sedative medication. Longer CPAP tubing, by increasing the physiologic dead space and mildly elevating inhaled CO2, also may improve complex sleep apnea. Because there are many treatment variables, patients with complex sleep apnea may have a less robust treatment response than patients with pure OSA, and they may need more overnight studies to test the efficacy of various therapeutic combinations.
Does sleep apnea cause insomnia?
Recent research implicates snoring and sleep apnea as contributing factors to insomnia in many patients. Insomnia often improves, and a number of insomnia patients reduce or cease hypnotic medication use, when their snoring is treated with an external nasal dilator or nasal medication, or when their sleep apnea is treated with CPAP.
Should I advise my patients to take their usual medications before sleep testing?
Many medications, such as antidepressants and benzodiazepines, may change the natural sleep structure, on the other hand, the sleep test itself can usually change the natural sleep structure. Antidepressants may worsen snoring, sleep apnea, and PLMS. Benzodiazepines may worsen snoring and sleep apnea, but they may improve PLMS. In general, as our referring physicians wish to answer a clinical question about a patient’s sleep under their daily conditions, we typically recommend that patients take all their daily medications on the night of sleep testing. We recommend that patients bring their night-time medications to the laboratory and take them after arrival. Our technologists are not licensed to dispense medications.
Does Comprehensive Sleep Care Center offer DME and follow up support to my patients diagnosed with sleep apnea?
Yes, being among Washington, DC metro’s area most experienced medical practices we offer a comprehensive approach from patient consultations with our sleep medicine physicians, to a full complement of sleep diagnostic testing, and an array of treatment options available at each of our centers. We understand using a CPAP machine can be intimidating. We’ve heard horror stories from patients who were simple given a machine, a one size fits all mask, and shown the door by their equipment provider Or how they had given up on their machine because they weren’t really sure it was working – or it was louder than their snoring. As our patients who have become religious CPAP users often report, once they got used to their CPAP, they found the literally got their life back with more energy, more focused mentally, and as an added bonus, their bed mates report also feeling the same way. The common refrain seems to be, ‘I wish I had done this sooner.’
It’s well know patient compliance with CPAP is typically low, and as it’s a race for healthcare dollars, how does Comprehensive Sleep Care tackle the issue of patient compliance?
At CSCC we do more than mask the sleep apnea problem Our CPAP compliance rate is more than double the national average for patient CPAP compliance. We’ve found that patients are most likely to be successful with their CPAP therapy with proper guidance and lots of encouragement! There’s a brief learning curve that can be shortened further through access to one-on-one professional support with our CPAP specialist. Because various published studies have indicated that the first month of PAP usage is crucial to compliance, as is the first year, we have developed a unique sleep apnea program, which includes:
- Intensive patient education and counseling
- Frequent contact to ensure your patient is adjusting well to CPAP therapy
- Web-based patient compliance management which allows our sleep specialists to:
- Keep an eye on your patients progress and usage
- Determine if their therapy may need fine tuning
- Determine if their mask may be leaking and impacting their results
- Ensure your patients are getting the maximum benefit of using the CPCP to treat their sleep apnea, health and overall well-being
Alternative treatments such as in-house oral appliance therapy, Provent therapy and surgery options are also available.
I’m hearing more about oral appliance therapy for sleep apnea. How does it work and is it covered by my patient’s insurance?
We are the only sleep health center in the DC metro area with dental physicians on staff to make it a fast, easy and cost-effective process for an oral appliance. An oral appliance is indicated as a first-line therapy for patients diagnosed with mild to moderate sleep apnea, or for those moderate to severe sleep apnea patients who are not able to tolerate CPAP.
An oral appliance is just an acrylic device that fits over the upper and lower teeth, almost like a set of retainers Oral appliances are worn at night, and work by anteriorly displacing the mandible and tongue, enlarging the retroglossal space and thus reducing upper airway obstruction.our onsite dentists make molds of your patient’s mouth, and send the molds to a dental lab to become the perfect fit oral appliance for your patient.
Oral appliances are generally well tolerated, safe, reversible and cost effective. Due to our dental team being part of our center, we are unique in that we can bill the patient’s medical insurance directly for the oral appliance therapy, and often save the patient up to a few thousand dollars in out of picket costs, and the inconvenience of going to a dentist.
Does Comprehensive Sleep Care Center provide insurance pre-authorization services for my patients?
Yes, our billing specialists will verify your patient’s insurance and benefits and seek authorization for any sleep test, and any DME that may be prescribed for a diagnosis of sleep apnea. We accept all insurances.