Notes from the ACCP meeting 10/2007

I did not attend the ACCP meeting in 2006, so this was my first time since their meeting in Montreal in 2005. One thing I noticed immediately was the number of physicians from overseas. I had not thought of this professional society as garnering that much interest from outside the country, but it did. I relish the opportunity to share our educational materials with physicians from outside the US and to help them help their patients be more adherent to therapy.

A first for the ASAA in a long time was sharing a booth with our colleagues at the National Sleep Foundation. Unlike NBC4 at the DC Convention Center some years ago, they joined us and I feel it worked out well. We will share a booth at the American Public Health Association meeting in early November.

I was able to attend a few of the educational sessions. One presentation was an update of the consensus conference hosted by the ACCP Sleep Institute last year. The presenters described the process used to formulate the consensus and the initial results. Their hope is to publish the results in the Spring of 2008 and to hope a follow-up conference on implementing a continuity of care strategy for OSA patient next year as well.

A second presentation and where I stood up to comment, was on the screening of hospital in-patients for OSA - pro and con. The pro side was offered by Dr. Anne O'Donnell of Georgetown University and Dr. Barbara Phillips of University of Kentucky (and incoming chair of the Sleep Institute) argued the con side. Having just been to the Anesthesiologist meeting in San Francisco I did have a couple things to say... including how I was feeling the "love" from the anesthesiologists, more so than from the sleep doctors - it got a chuckle.

The third presentation offered an interesting insight. Dr. Peter Gay from the Mayo Clinic provided an excellent overview of the technological advances in continuous positive airway pressure therapy from when it was first created by Dr. Colin Sullivan in 1981. The title of his talk was "Industry and Sleep Physician: Rowing in the Same Direction?" His thesis is that the advances in PAP therapy have gotten ahead of the sleep physician/researchers. Changes in PAP sleep apnea treatment are being dictated by forces other than changes in physician's understanding of how to treat the condition. Interesting food for thought.

ACCP is in Philadelphia next year.

Email to a young OSA patient

I got the following email today...

I am 31 years old and I have been told that I have sleep apnea, I currently have begun using a CPAP machine and just wanted to know will I have to use that device for the rest of my life and how do I become a memeber of the ASAA.

My thoughtful response at 7 in the morning...

Thank you for writing... the answer to your first question is hard. It depends a lot on why you developed sleep apnea... genetics (runs in the family), excess weight, naturally occurring narrow upper airway. I have heard of people losing a significant weight through improved diet, increased exercise and consistent use of CPAP being able to leave the machine behind... there are others who just feel so much better from getting a good night's sleep that it does not matter to them that CPAP has become a part of their nightly routine.

At this point... I would worry less about that and more about making sure you have the right equipment and are getting the most effective treatment possible. Hopefully it won't make a difference.

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News from the ACCP conference later... stay tuned.

Can you spell... an·es·the·si·ol·o·gist

I am among the fortunate to have required general anesthesia only a couple time in my life and the second was after I had become the E.D. of American Sleep Apnea Association. The anesthesiologist, learning of my relationship to the association, came in before the procedure and talked my ear off (in a nice way) about the problem of undiagnosed OSA patients coming in to the ambulatory surgery center and she having to deal with them... meaning not be a party to their sudden or not so sudden demise after administering anesthetics.

It makes complete sense that an anesthesiologist would be concerned about an undiagnosed OSA patient. According to Dr. Johnathan Benumof, whose presentation I attended on Saturday, there are three points at which the anesthesiologist should be concerned about an OSA patient, treated or untreated... intubation - administering the anesthetic too soon may cause the airway to close thereby making it very difficult to put the breathing tube in the throat. Extubation - for the same reason, but in reverse and pain management, post operative... many of the opiod-type pain medicines can suppress breathing and with the OSA patient the problem is compounded.

Dr. Benumof's presentation to a nearly standing room only hall provided an excellent overview to OSA and explained, briefly the guidelines adopted two years ago by the American Society of Anesthesiology on management of the OSA patient.

I was able to attend a clinic forum where the case study was a man who is suspected of having sleep apnea come in to an ambulatory surgical center for repair to his rotator cuff. It was interesting to listen to their discussion, many of whom believed that the surgery, for a number of reasons should be done in a hospital setting where it would be possible to monitor the patient after the surgery... since the surgery itself is not the problem, but the pain management afterwards is.

Dr. Benumof admonished those assembled during his talk that they were likely the last physicians to see the patient and it was their responsibility to make sure they received the proper care. It is very true... on more than one occasion, the surgery has been a success, but the patient dies in the recovery room or "out on the ward" because they were not properly monitored or given the correct analgesia given their diagnosed and not announced or their undiagnosed obstructive sleep apnea.

For those with sleep apnea reading this... please say something before going in for surgery or a procedure requiring anesthetic (think colonoscopy)... click on the links below for more information. If you have not been diagnosed and it is clear from looking at you and asking a couple of telling questions that you are at risk of OSA... you may find yourself diagnosed before you leave the hospital after having surgery. Assuming you leave under your own steam and not feet first.

The conversations in the exhibit hall have centered on our most recent Patient Education Bulletins on CPAP in Hospital and the checklist. Our web site has more information for the anesthesiologist, but looking at it, it needs some work.

There is potential for great synergy with this group of doctors who are very interested in this subject. I will move it high on my list of relationships to explore.

Next week Chicago and the American College of Chest Physicians

PS... found in my fortune cookie after dinner last night... You could make a name for yourself in the field of medicine... nice thought!

Traveling to Mecca

I am in San Francisco for the annual meeting of American Society of Anesthesiologists... our association has exhibited at their meetings for a number of years. They have always had an interest in managing the sleep apnea patient before, during and after surgery. In the past couple of years they have introduced a set of guidelines for managing the patients... so our presence here helps to reinforce the importance of identifying and managing apnea patients. This is the first one of these I attend, so it will be interesting. I will report on details in another entry.

On Friday, I went to what I call Mecca for the sleep field - the campus of Stanford University. I say Mecca, because it is the home of the Stanford University Center of Excellence for the Diagnosis and Treatment of Sleep Disorders. Housed here is the Sleep Disorder Clinic founded in 1970 by Drs. William Dement and Christian Guilleminault (both whom I have mentioned in this blog before). In addition to Dement and Guilleminault are world-renowned sleep surgeons Nelson Powell, Robert Riley and Kasey Li. Dr. Emmanuel Mignot, and the Stanford Center for Narcolepsy was the first to that narcolepsy-cataplexy is caused by hypocretin (orexin) abnormalities in both animal models and humans. With the School for Sleep Medicine, it is the center of the sleep universe.

While I was there I spent time with Bill Dement and together we attended the weekly Grand Rounds presentation. The subject of the talk by Craig Harris on hibernation and its relate to sleep.

Bill and I spent a long time talking about the course he has presented at Stanford to undergraduates on Sleep and Dreams. It is the most popular course with undergrads at the University. Bill would like to see the course taught at all 4,000 colleges and universities around the country – a tall order indeed. He has put together the course slides and the course textbook – The Stanford Sleep Book. My hope is to work with him to get the course offered at one university in the Washington area.

The treat of the day, was to attend Bill’s talk… Sleepless at Stanford, which he did for the alumni who had returned for Homecoming weekend. I heard this talk before, and I always marvel at the energy and enthusiasm of this nearly 80-year-old man. I can only hope to have this much verve when and if I get to 80.