Author: Michael Kelley
AHI only part of the story
A study published in Nature and Science of Sleep contends that “continued indiscriminate use of the apnea-hypopnea index (AHI) should be discouraged.” Instead, researchers suggest that numerous alternative measures be incorporated to provide the total sleep picture. Determining exactly what is being counted during the AHI is thoroughly examined, with researchers concluding that “it is inconceivable that all apneas and all hypopneas are the same kind of exposure, as far as effects are concerned. For instance, the clinical consequences of not breathing for 60 seconds cannot be identical to the consequences of shallow breathing for 30 seconds, and the consequences of accompanying hypoxemia surely depend on its magnitude and duration, not on an arbitrary cutoff point.” Many of the arguments and/or alternative measures presented presented in the full study extend to other ratio variables that are commonly used in sleep research, such as the arousal index, percentage of time in desaturation, and percentage of time in each sleep stage. “In fact, the modeling of ratios has been harshly criticized in other branches of science as well,” write researchers. “However, the lessons offered are far more general. First, a variable that is useful in clinical practice is not necessarily the preferred variable in biomedical science. Second, we should never accept a new variable into science on the basis of feelings or authority. Third, if the analyzed variable is a derived variable, researchers should explicitly state which natural variable they claim to be measuring. And if they are unwilling to commit to a clear theory, they are not in the business of science.” Click Here to read the full study.
Lessons Learned about Airway and Respiratory Illness at the World Trade Center
There are few events in our collective consciousness that have united us as a country like the events of 9/11. Everyone knows where they were on the day, what they were doing and how they felt. Lessons learned by early responders on that day have taught us a great deal about dealing with disaster and managing the aftermath. The following abstract is interesting in the context of our knowledge of the health effects on the men and women who stayed onsite to clean up the rubble. At the time it was well understood that the dust must be toxic or that breathing the dust would have some detrimental impact on the health of the cleanup teams. Following is an excerpt from a report by the City of New York entitled “What we know about the health effects of 9/11”. Respiratory Illness Those exposed to WTC-related dust were more likely to develop respiratory symptoms, sinus problems, asthma or lung problems. One in 10 Registry enrollees developed new-onset asthma within six years of 9/11, three times the national rate. New cases were highest during the first 16 months after 9/11. Intense dust cloud exposure on 9/11 increased the risk of developing asthma. These groups were especially at risk: Rescue, recovery and clean-up workers who arrived early at the WTC site or worked at the WTC site for long periods of time Lower Manhattan residents who didn’t evacuate their homes Lower Manhattan residents and office workers who returned to homes or workplaces covered with a thick coating of dust People who both lived and worked in lower Manhattan after 9/11 Steep declines in pulmonary function first detected among firefighters and emergency medical service (EMS) workers within a year of 9/11 have largely persisted, even among those who never smoked. It is estimated that four times as many firefighters and twice as many EMS workers had below-normal lung function for their ages six to seven years after 9/11 as they did before the attacks. Among the few active smokers, pulmonary function declines were even greater than for non-smokers. Studies also have identified persistent abnormal pulmonary function in other WTC rescue and recovery workers, including police, and in Lower Manhattan residents and area workers. Seven to eight years after 9/11, continuing lower respiratory symptoms were identified in area workers and people living in Lower Manhattan at the time of the attack. The prevalence of symptoms correlated with the degree of WTC disaster exposure and abnormal pulmonary function. Both epidemiologic and clinical studies demonstrate substantial co-morbidity (co-occurrence) of respiratory illness and mental health conditions in WTC-exposed groups. This abstract set out that testing done onsite using forced spirometry the standard of care to measure lung function at the time, appeared normal. It is very possible that the early diagnosis of diminished lung function of this kind requires much more specific diagnostic protocol such as Impedance oscillometry (IOS). DISTAL AIRWAY FUNCTION IN SYMPTOMATIC SUBJECTS WITH NORMAL SPIROMETRY FOLLOWING WORLD TRADE CENTER DUST EXPOSURE. Oppenheimer BW, Goldring RM, Herberg ME, Hofer IS, Reyfman PA, Liautaud S, Rom WN, Reibman J, Berger KI. Source Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York University School of Medicine, New York, NY 10016, USA. Abstract RATIONALE: Following collapse of the World Trade Center (WTC), individuals reported new-onset respiratory symptoms. Despite symptoms, spirometry often revealed normal airway function. However, bronchial wall thickening and air trapping were seen radiographically in some subjects. We hypothesized that symptomatic individuals following exposure to WTC dust may have functional abnormalities in distal airways not detectable with routine spirometry. METHODS: One hundred seventy-four subjects with respiratory symptoms and normal spirometry results were evaluated. Impedance oscillometry (IOS) was performed to determine resistance at 5 Hz, 5 to 20 Hz, and reactance area. Forty-three subjects were also tested for frequency dependence of compliance (FDC). Testing was repeated after bronchodilation. RESULTS: Predominant symptoms included cough (67%) and dyspnea (65%). Despite normal spirometry results, mean resistance at 5 Hz, 5 to 20 Hz, and reactance area were elevated (4.36 +/- 0.12 cm H(2)O/L/s, 0.86 +/- 0.05 cm H(2)O/L/s, and 6.12 +/- 0.50 cm H(2)O/L, respectively) [mean +/- SE]. Resistance and reactance normalized after bronchodilation. FDC was present in 37 of 43 individuals with improvement after bronchodilation. CONCLUSIONS: Symptomatic individuals with presumed WTC dust/fume exposure and normal spirometry results displayed airway dysfunction based on the following: (1) elevated airway resistance and frequency dependence of resistance determined by IOS; (2) heterogeneity of distal airway function demonstrated by elevated reactance area on oscillometry and FDC; and (3) reversibility of these functional abnormalities to or toward normal following administration of a bronchodilator. Since spirometry results were normal in all subjects, these abnormalities likely reflect dysfunction in airways more distal to those evaluated by spirometry. Examination of distal airway function when spirometry results are normal may be important in the evaluation of subjects exposed to occupational and environmental hazards. Chest. 2007 Oct;132(4):1275-82. Epub 2007 Sep 21. This is another article on the same topic; Respiratory Symptoms and Physiologic Assessment of Ironworkers at the World Trade Center Disaster Site
Bad Cholesterol linked to increased pediatric asthma and airway obstruction
Blood lipid profiles are associated with childhood asthma, airway obstruction, bronchial responsiveness, and aeroallergen sensitization, researchers from Denmark report. Dr. Hans Bisgaard from the University of Copenhagen told Reuters Health by email that he was surprised by the “significant association between serum lipids and asthma and allergy. This association is similar to the association found between serum lipids and other chronic inflammatory disorders.” Previous studies examining the relationship between the blood lipids and asthma have yielded ambiguous results, despite the association of hypercholesterolemia with a skewing of the adaptive immune response toward a TH2-oriented response, which is also seen in asthma and related disorders. Dr. Bisgaard’s team investigated the possible relationship between blood lipid levels, asthma, lung function, sensitization and allergic rhinitis in 296 7-year-old children born to mothers with a diagnosis of asthma. Increasing LDL-cholesterol levels were associated with a 93% increase in the odds of concurrent asthma after adjustment and a significantly increased risk of airway obstruction, the researchers reported July 3 in the Journal of Allergy and Clinical Immunology. In contrast, high HDL-cholesterol levels were associated with significantly improved airway flow, decreased bronchial responsiveness, 73% lower odds of sensitization against aeroallergens, and a non-significant reduced risk of allergic rhinitis. High triglyceride levels were significantly associated with a doubling of the risk of aeroallergen sensitization, but not with the other measures. Dr. Bisgaard said there are no immediate clinical implications of these findings. “The study is seeking to understand the origins and mechanisms of chronic inflammatory disorders such as asthma and allergy,” he said. “This insight will build the foundation for future prevention and treatment.” The researchers add, “Further longitudinal studies are required to evaluate a potential modifiable link between an unhealthy blood lipid profile and asthma and allergic sensitization.” Dr. Yang-Ching Chen from Taipei City Hospital in Taiwan, who was not involved in the new work, also found a link between LDL-cholesterol and asthma in an earlier study. “Our data identified a trend of increasing levels of total cholesterol and LDL-cholesterol in the group order obese asthmatics > non-obese asthmatics > obese controls > non-obese controls,” Dr. Chen told Reuters Health by email. “Prevention of childhood obesity and related hyperlipidemia should be emphasized in obese asthmatic children.” “Further studies might focus on the possible detailed mechanisms of hyperlipidemia in asthmatics,” Dr. Chen added. References: http://www.consultant360.com/story/blood-lipid-profile-tied-childhood-asthma-and-bronchial-responsiveness http://bit.ly/1fPYz3U J Allergy Clin Immunol 2015. (c) Copyright Thomson Reuters 2015.
Could the CPAP machine really be the dirtiest place in the home?
CPAP machine may not be the first item that comes to mind when you consider the dirtiest surfaces in your household. But scientists say that some of the filthiest places in our home are where we would least expect. Take a minute to think – What is the dirtiest surface in your home? Is it the door knobs? The remote? How about the toilet seat? All of these are likely offenders. But they might not be as dirty as you think. The toilet seat, with only about 50 bacteria per square inch, is the one of the cleanest surfaces in your home. Because we all fear the bacteria that might lurk on the toilet seat, we regularly clean it. So what, then, are the dirtiest surfaces in the home? In fact, some of the dirtiest surfaces in the home are the ones we forget to clean. According to Dr. Chuck Gerba, a microbiologist from the University of Arizona, there are about 200 times more faecal bacteria on the average cutting board than the toilet seat. Even dirtier than the surfaces we forget to clean are the surfaces that provide an ideal home for bacteria. The wet environment in a kitchen sponge, for example, is home to some 10 million bacteria per square inch, says Gerba. But what about the warm, humid environment of your CPAP equipment? A study conducted by Dr Sandra Horowitz of Brigham Women’s Hospital concluded that CPAP masks are a source microbial contamination. CPAP equipment, commonly used as treatment for sleep apnea, should be washed daily. But researchers reported that a variety of bacteria were found inside CPAP machines and CPAP masks, even the pathogen Staph aureus. While hand washing with soap is generally accepted as the best way to clean CPAP equipment, this daily process is often neglected. Many CPAP users simply forget to clean their equipment, potentially allowing bacteria and fungus to compound inside. The Best Method for Cleaning Your CPAP or BiPAP machine fromJessica Cormier on Vimeo. But savvy CPAP users are turning to an innovative device released earlier this year by Massachusetts-based Better Rest Solutions. The SoClean, an automated sanitizer, uses activated oxygen to kill the mold, viruses and bacteria that grow inside CPAP equipment. Better yet, no disassembly is required to run the SoClean. “Quite frankly, there is nothing else like the SoClean available today,” says Better Rest Solutions president, Michael Schmidt. “Whether it’s for the home user, or in an institutional setting, we feel that it will soon become the gold-standard for CPAP machine sanitizing.” The SoClean is available for purchase through CareFusionhttp://bit.ly/Tc8vGb, or online directly atwww.betterrestsolutions.com .
ResMed Narval CC Case Study: Size Matters!
One of the most intriguing features of the ResMed Narval CC is its small footprint. I find most patient’s transitioning from an acrylic appliance frequently comment on both the small size and the increase in comfort, as compared to their previous appliance. But what about new patients to Oral Appliance Therapy, where do they stand on this issue? Recently, I made a Herbst appliance for a patient that had many crowns that he was thinking of replacing in the future, but was not ready to act on. He had a very severe level of apnea (AHI = 36, 62 in supine position) and could not tolerate CPAP at all, even after trying several masks. So, we decided to proceed with an appliance that would be more forgiving when adjusting around future crowns, even allowing for a full reline if necessary; the Herbst. Unfortunately, at the insert appointment, the patient could not tolerate wearing the Herbst at all. He had difficulty establishing lip seal and felt that it was too much of a mouthful. I sent it back to the lab to see if they could reduce the vertical and bulk of acrylic and re-inserted it. The patient took it home and returned the very next day, begging me to make him a Narval (the appliance we decided against due to the crown work he was planning to do in the future). Seeing the sincere distress in his eyes, I agreed. Upon delivery of the Narval, he was very pleased and after a couple of adjustment appointments we established through a sleep study that his very severe sleep apnea had been resolved (AHI = 4.1, 5.3 in supine position). Needless to say, he was a Very Pleased Patient! What makes this case interesting is the size of his appliances. This gentleman has a VERY large dentition. Quite frankly, I have never seen a dentition of this size and in fact, this was the very first time I had such an experience with a Herbst, an appliance I have used successfully for years. In the photo’s above you will find the Patient’s Narval and Herbst, alongside the standard Sample Narval and Herbst that I show patients at consults. Note the remarkable difference in size! ResMed literature discusses the use of the Narval CC for very petite individuals that would logically have difficulty tolerating a bulky acrylic appliance, but in addition, I think this case study provides good support for the use of a Narval CC nylon appliance for very large dentitions, where the size of the final acrylic device would be so large as to reduce patient adherence to therapy. Of course, not everyone has as large a dentition as this gentleman and thankfully this is uncommon. However, if we think on these parameters as being on a continuum, small to large, I feel it prudent to consider the size of a patient’s dentition when selecting the most appropriate appliance. Clearly, fishing isn’t the only area that size matters! Stay tuned for an update to the “Practical Pearls” eBook on Nylon Appliances. It should be ready to post by late August. If you have an interesting case study you would like included please feel free to share. John Viviano DDS D ABDSM SleepDisordersDentistry.com Website SleepDisordersDentistry LinkedIn Discussion Group
Treatment Acceptance Based on Patient Qualification- The Predictor Device®
Over the last 20 years there has been an ever increasing use of oral appliances for the treatment of obstructive sleep apnea (OSA) and sleep disordered breathing (SDB). In Scandinavian countries the preferred interventional therapy for the mild to moderate sleep apnea patient has been an oral appliance due to improved patient compliance. Only when the patient has severe sleep apnea or when there are other clinical factors to consider is CPAP recommended. In the United States the American Academy of Sleep Medicine (AASM) has recommended Oral Appliance Therapy as a first line therapy for mild to moderate OSA since 2006. In America the dominance of CPAP therapy is quickly surrendering to oral appliances due to compliance concerns, changes in insurance reimbursement and greater access to home sleep testing. Many clinicians have been reluctant to prescribe a costly custom fabricated oral appliance due to concerns about effectiveness of oral appliances. The true barrier to oral appliances has been the difficulty to predict a successful outcome. Today we have now have ApneaRx®, The Predictor Device® which for a low cost can accurately predict a patient’s success with an oral appliance. ApneaRx is a prefabricated oral appliance that can be boiled, cooled and custom fit in less than 5 minutes. Once fit, the device can be micro adjusted in 1mm increments, which meets prescribed AASM criteria. I find this product particularly interesting because the ApneaRx is designed as a temporary device for predicting success with a custom oral appliance however it is robust and durable enough to be worn every night. The importance of this last feature is that oral appliance therapy is critically affected by the condition of the patient’s muscles and ligaments which can relax and adapt over time. It is suggested that the patient wear the appliance for 2 weeks before a titration study is undertaken in order for this adapted condition to occur. ApneaRx is light comfortable and predictive of success with a more expensive custom fabricated oral appliance. Unlike those considering CPAP devices, which patients can “try before they buy,” those considering OA treatment must rely on the expertise of their physician in being able to predict treatment success and be willing to pay without certainty about the outcome. CPAP therapy is so well suited to the in lab sleep study or polysomnogram that the patient and their physician are not only confident their OSA is resolved with the CPAP, but a prescription can be written with a therapeutic pressure. In order to try a custom oral appliance for the treatment of OSA a patient prior to ApneaRx required a custom oral appliance fabricated at a cost of thousands of dollars with no guarantee of success. Consistent in all studies of Oral Appliance therapy is that OSA is not adequately alleviated in all patients. Naturally patients and their physicians are concerned that a large investment without any ability to predict success with the oral appliance makes a decision difficult, and to some the decision feels risky. So who are these patients? Studies indicate that there are a tremendous number of patients for whom the promise of a good night sleep using CPAP did not translate into nightly usage. CPAP acceptance and compliance are between 35% – 50%. A significant number of patients (ranging from 30% to 80% in various studies) demonstrate an average CPAP usage of less than 4 hours per night.[1][2] Great candidates for oral appliance therapy also tend to have a positional component to their condition. Supine-predominant OSA (a higher AHI in supine compared to lateral sleeping position) has been considered favorable for treatment success.[3] Some patients actually are predisposed to oral appliance therapy based on their unique facial features. Craniofacial features assessed by lateral cephalometry, including shorter soft palate length, lower hyoid bone position, greater angle between the cranial base and mandibular plane, and a retrognathic mandible, are also associated with favorable treatment outcome.[4] Clearly in order to serve the need of treating this patient population with a therapy that they could accept from a clinical and lifestyle perspective a predictive appliance needed to be developed. This type appliance not only required the ability to be fabricated at low cost but also titrated in 1mm increments and be easily adjusted in a diagnostic setting like a sleep lab or in a patients home, ApneaRx fits all of these criteria. A pilot study by a team of clinicians from Kaiser Permanente in Fontana CA evaluated 117 patients and found the ApneaRx 100% predictive of success with a custom oral appliance. [5] Over time dentists have tried many ways to predict success with an oral appliance from cone beam imaging, to acoustic resonance, to kinesiology there just never seemed to be a low cost predictor of success with an oral appliance for obstructive sleep apnea. The clinical challenge has always seemed to be that ‘the patient was fitted while awake and treated while asleep.’[6] Best practice standards require that a Board Certified Sleep Physician form a medical diagnosis of OSA, before treatment is initiated. It is important that baseline values be established and a treatment protocol followed that takes into account degree and severity of the patient’s condition. Single-night titration methods, allowing advancement of the mandible during sleep, have shown more promise in indicating likely treatment success and therapeutic level of advancement in a small number of patients using prototype devices. This method involves use of a remotely controlled intraoral device during an attended sleep study to incrementally advance the mandible until sleep disordered breathing events are eliminated, analogous to a CPAP pressure titration study.[1]If a custom oral appliance is the selected therapy, a follow-up Polysomnogram (PSG) or Home Sleep Test (HST) must be ordered to confirm that post treatment values fall into an acceptable range. In summary, while the US sleep apnea market has been built by selecting CPAP as the first line of interventional therapy, oral appliances are expected to equal, or surpass CPAP therapy in a few short years, as is now the established standard of care and first line interventional therapy for many other countries. The customized nature of oral appliance therapy requires additional diagnostics be performed to assure the physician and the patient that the therapy is in fact a viable option and to confirm that the investment in the custom oral appliance is one that will meet, or exceed the minimal clinical requirements. The ApneaRx®, ‘The Predictor®’ is the first and only such device with a peer reviewed independent clinical study that validates oral appliance therapy. It is no wonder that many physicians are now writing their prescriptions, ApneaRx / CPAP therapy. [1] Kribbs NB, Pack AI, Kline LR, et al., authors. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis. 1993;147:887–95 [2] Reeves-Hoche MK, Meck R, Zwillich CW, authors. Nasal CPAP: an objective evaluation of patient compliance. Am J Respir Crit Care Med. 1994;149:149–54 [3] Sutherland K; Vanderveken OM; Tsuda H; Marklund M; Gagnadoux F; Kushida CA; Cistulli PA; on behalf of the ORANGE-Registry. Oral appliance treatment for obstructive sleep apnea: an update. J Clin Sleep Med 2014;10(2):215-227. [4] Sutherland K; Vanderveken OM; Tsuda H; Marklund M; Gagnadoux F; Kushida CA; Cistulli PA; on behalf of the ORANGE-Registry. Oral appliance treatment for obstructive sleep apnea: an update. J Clin Sleep Med 2014;10(2):215-227. [5] Dennis Hwang, Jeremiah Chang Feasibility Pilot Evaluating the Use of Pre-Fabricated Titratable Mandibular Poster Presentation AASM 2013 [6] Randy Clare; Low Cost-High Value “Predictor Device” for Oral Appliance Therapy- Economics or Oral Appliance Therapy; SleepScholar.com online 2015 3.31
Sleep Diagnostics Industry Overview
Sleep awareness has blossomed over the last decade, and it’s hard to find anyone who believes the market is anywhere near its peak. Consumers and members of the medical community increasingly agree that better sleep is a must for improved overall health. With all that positivity, Jeremy Andra still wonders why the business climate surrounding sleep remains unsettled. “We know things are changing, and have to change even more with heath care the way it is right now,” says Andra, sleep products manager for Washington-based Cadwell Laboratories. “It’s not going to be back the way it was. Do we want to sit around and wait for insurance companies to figure it out? I don’t think so, because they usually get it wrong. In fact, many misunderstandings can happen.” As one example, Andra points out that the phenomenon of home sleep testing was never meant to hurt the sleep market, but instead to help it. That message may be getting through in much the same way that it did years ago in the cardiology market. “Cardiologists once complained that family practice physicians wanted to do their own EKG strips,” explains Andra, who has opened up more than 100 sleep clinics in a lengthy sleep-related career. “They were crying foul saying this will hurt us, and you don’t know enough about the heart like we do. Family practice came back and said, ‘You’re right, but we do know what a normal EKG looks like, and if it’s abnormal, we’ll send them to you.” Andra is keen to examine the progress of relevant specialties in an effort to develop and expand Cadwell’s sleep diagnostic products (which includes digital video software that allows users to display video movement as a channel in recording montages). Ultimately, Andra is intent on bringing disparate groups together to better all facets of the sleep industry. Sleep Diagnosis & Therapy sat down with Andra to talk about better ways that sleep physicians, non-sleep physicians, and sleep labs can work together more effectively. Matching business savvy to clinical excellence is a top priority in this dialogue. You compared the sleep world to the cardiology situation from many years ago. Once the turf wars subsided in cardiology, what was the outcome? The cardiologists became so busy they didn’t know what to do. When in doubt, family practice will send patients to specialists to be sure. I think home sleep testing was really meant to be the same thing where if it looks like something is going on, patients are sent to a specialist. Why is it so important for this to happen in the real world? It’s necessary if we want to take care of the population that we are still not reaching. Home sleep testing offers a chance to find the people who are having a problem, and do it very affordably. If it’s inexpensive, people are going to do it. Then we can let the sleep labs do what they were meant to do—take care of the complex problems. For patients who have insurance, and the deductible has been met, these home sleep tests are maybe $40 for the patient (out of pocket), and they don’t mind getting the test because it’s inexpensive. Once something is found, then they don’t mind spending the money to take care of it. Without insurance, it may be $200 to $300 for a home study. How are home sleep tests an improvement over the past? In the past, we were pretty sure patients had sleep apnea just by looking at them and talking with them. At the time, we could not do cheaper or easier tests. When they found out there was a problem, they did not mind taking care of the problem. They just don’t want to spend money to find out there is nothing. What does your company do to grow/expand sleep and dental opportunities? It’s all about becoming a multi-modality type of industry. Right now, you need to be able to do more with what you have. A prime example is when I was out in my own sleep world, we would try to create areas where we could do EEGs, sleep, dental, and run the regular practice all in one area so we had the same overhead. If you had an area during the night that wasn’t being used, that would be the ideal area for your sleep lab, and during the day it is also being used so you get full service out of it. When we look at equipment we do the same thing. We want to test a new type of patient or see how can we draw more patients in, or how can we tie communities together to get more referrals. That’s my direction since I’ve joined Cadwell. Let’s try to get a better referral source. How would characterize the level of compliance these days among sleep patients? There’s a reason why CPAP compliance has gone down. You talk to people involved and it’s very confusing. Originally, CPAP machines were bigger, louder with much fewer comfort technologies. The original CPAP mask was glued to the face, but we had a higher compliance rate back then. They keep making better machines and the compliance is going down. There is something that we are missing. Not all patients are alike and not all patients should be treated with the same solution. Is there something we’re missing? What factor do you think the industry is failing to take into account? The truth is when we originally started in this industry, we were mostly taking the train wreck patients who were really going to die if they did not take care of their severe sleep apnea. These were really sick patients, and they used CPAP units because they had to. Now sleep disorder awareness has really gotten out in the public. You can’t listen to the news without somebody talking about sleep. You’re getting a new demographic in, a younger demographic, and they aren’t to the point where they feel like it’s a life or death situation. That is where different solutions for therapy as well as for the diagnostic testing needs to come into play. What is the attitude of the younger person and how should we respond? Why is it important for diagnostic manufacturers to pay attention to these trends? In the testing industry, we have to be keenly aware of the changes. It’s not as simple as ‘use’ the same therapy on everybody. When we’re reporting and using this technology, we need to make sure it’s compatible with the different products coming out on the market. For example, how does the diagnostic equipment deal with a titration of an oral appliance or a split night study using an oral appliance? How does the clinical side compare to the business side of sleep these days? The business of sleep medicine is much more difficult than the medicine of sleep medicine. It’s almost worth getting some business as part of your medical degree. People are looking for help with their business now and looking for business models that will work. There used to be so many choices in equipment companies. Now we wonder; Which products will be discontinued? Do I want to invest in something and try to make it work only to find out that the product is not going to be around? What kind of equipment are people looking for these days? People want the very lowest price they can get. But they really should ask, “What are my needs as a business person, and how am I going to run my business?” If you’re going to be a single lab with a few beds, you should probably look for the lowest price system. If you want to have several labs or more than one testing site, you might want to look for one that’s better at networking and tying things together. At Cadwell, We are trying to get equipment here that ties in to sleep labs with home sleep testing and physicians in local communities. At the end of the day, if people are out buying our equipment, and that equipment is bringing in more referrals to the local sleep lab, rather than competing against them—it becomes easy to pay for that equipment. It has value, and draws business in.
Not all that wheezes is asthma (or COPD)!
How is it possible, with supporting literature, along MD groups like American Medical Association (AMA) and even government sponsored spirometry initiatives National Quality Forum (NQF) 0091 COPD Spirometry Evalution (1) stating that spirometry has to be done to “prove” Chronic Obstructive Pulmonary Disease (COPD)/Air Flow Obstruction (AFO), and simple tools like the COPD-population screener, that Primary Care Physician (PCP) offices are STILL neglecting to do a simple test that IS BILLIABLE! When you go to your PCP and complain of chest pain or tightness, they do an ECG as part and parcel to your visit. Why are we NOT doing spirometry when there’s a complaint of Shortness of Breath (SOB)? Or at the very least- a query/screener like the COPD-ps that can define if we need to perform spirometry or not. “Kaminsky_all that wheezes is not asthma” shows that anywhere from 20-40% of people labeled as COPD, do not actually HAVE COPD. They were empirically diagnosed and NEVER DID SPIROMETRY. Then there’s the burden of that cost on patient care, mismanagement, and worst of all readmission for something they don’t have. “VA must do spiro for COPD diagnosis” showed that apprx 40% of patients carrying the empirical diagnosis COPD, were genuinely sick, but NOT with COPD. They fall into these categories, none of which should come as a surprise- Congestive Heart Failure (CHF), obesity, sleep apnea, or hypertension. Previous studies conclude that only 1/3 of newly diagnosed COPD patient have undergone spirometry. It has been documented many times, that the clinical exam is not adqequate in predicting airflow obstruction, nor can it define the nature of airflow obstruction. Overall, this type of empirical care is wasteful, inaccurate, ineffective, and certainly not patient centered. COPD strains hospital resources and dollars; imagine the impact to hospital resources, dollars, and most importantly patient quality of life, if only 20% of those patients were properly managed! When you go to your PCP and complain of chest pain or tightness, they do an ECG as part and parcel to your visit. Why are we NOT doing spirometry when there’s a complaint of SOB? Or at the very least- a query/screener like the COPD-ps that can define if we need to perform spirometry or not. With the estimates of this disease based on impaired lung function being in the 24million range, we simply cannot afford a single incorrectly diagnosed patient.