The Perfect Storm - Arriving at a Diagnosis

Two stories... there was a time, a while back, when a noted physician invited a group of residents into a patient's room to show them someone with sleep apnea. A condition he said that they might only see a couple of times in their professional career. Another noted sleep medicine physician when talking about diagnosing people with sleep apnea says that janitor who works in building is capable of "diagnosing" patients while they sit in the waiting room.

Sleep disordered breathing in the form of obstructive sleep apnea is not rare, far from it. The increasing age of the population and the increasing body mass index is making all too prevalent. Sadly, it becoming more common in children as well..

What are the tools required to determine whether obstructive sleep apnea is present and sufficiently severe to warrant a therapeutic intervention. How much information is enough information to say yes, this person has sleep apnea and needs treatment. 

There are some who believe the only definitive way to determine whether sleep apnea serious enough to requirement treatment is using a sophisticated research tool - monitored in-lab polysomnography (PSG). PSG collects a lot of information - it should, it is a valuable research tool - but could it be TMI when considering that sleep apnea is not as the earlier noted physician indicated a rare condition... a medical curiosity.

The janitor in the sleep lab determining who has the condition may likely be too much in the other direction - not enough to assess what are likely the less severe cases (mild to moderate including Upper Airway Resistance Syndrome).

Technology exists, actually it has existed all along that provides enough information to conclude there is a condition to be treated. In fact, the technology is getting more and more sophisticated - able to record more channels of information for the physician to use to arrive at a diagnosis.

The use of out of center or home sleep testing, as is becoming the requirement of health insurance companies through their proxies, will certainly increase the number of diagnosed patients. But, if once diagnosed the patient doesn't have someone trained to guide them to the appropriate treatment and help them manage the condition - we have accomplished nothing, perhaps made the situation worse.

If the first element of the Perfect Storm was a condition that was poorly understood in terms of its prevalence in the general population, the second element is how we arrive at a diagnosis for a condition once thought to be rare, but that is so common the janitor in the sleep lab could recognize it (at least the more severe cases).

                                                     (to be continued....)

The Future of Sleep Medicine - The Perfect Storm

A "perfect storm" is an expression that describes an event where a rare combination of circumstances will aggravate a situation drastically. The term is also used to describe an actual phenomenon that happens to occur in such a confluence, resulting in an event of unusual magnitude.

That is how I would described what happened with the diagnosis and treatment of sleep apnea and why "righting the ship" to get those who need help will be very difficult.

The first circumstance contributing to the perfect storm is the condition itself. Sleep apnea was original considered to be a rare disease that affected only middle-aged overweight men. It was originally called Pickwickian syndrome after the character from Dicken's novel "The Pickwick Papers" - Fat boy Joe. It was something that a physician might see one or two cases in their entire working career....

In fact, it is a common and highly prevalent condition - that up until the mid 1980s was treated by means of a surgical intervention - a tracheotomy. The advent of Positive Airway Pressure therapy invented Colin E. Sullivan changed everything.

But how to diagnose it and how to dispense the therapy....

(To be continued)

Why sometimes I feel like Jimmy Stewart....

A couple years back I had the good fortune to attend and present at the annual meeting of one of our sister organizations - the Sleep Apnoea Trust. My talk was on OSA in the USA - clever title, I thought anyway. One of the images I used was of Jimmy Stewart from the Hitchcock film Rear Window.
The point I made in the presentation was that I am an observer of the practice of sleep medicine as respects the diagnosis and treatment of sleep apnea.

Lately, I am reminded of the Jimmy Stewart and the film for another more disturbing reason. I feel like Jimmy as I watch powerlessly through the rear window as a crime is being committed against an innocent and unsuspecting victim.

The crime - diagnostic and treatment for sleep apnea is not being provided based on a care management model as opposed to episodes of care. The sleep apnea patient is now even more on their own than they were earlier. While home sleep testing is more efficient and will get many more people into the treatment pipeline - without the intervention of a qualified sleep medicine physician to provide guidance or at a minimum, consult on the appropriate treatment pathway - the patient is more likely to get lost - go without effective treatment.

Who is the Raymond Burr character, the villain, in this thriller? You could say the healthcare system is to blame - with its focus on sick care and payment for procedure versus payment for improved outcomes. But the payors starting with Medicare can also be faulted for not fully understanding the condition they are trying to address with their reimbursement model.


The use of Positive Airway Pressure as a non-surgical intervention for the treatment of obstructive sleep apnea is still relatively new. Dr. Colin E. Sullivan published his landmark paper in the journal The Lancet on April 18, 1981, barely a generation ago. 

At the time, it was not clearly understood what the prevalence of the disease was, nor was there a conscious effort made to understand the best way to dispense the therapy. The default was to use the channel used to dispense the therapy used for other pulmonary disorders - durable medical equipment companies that dispense oxygen therapy. 

Positive Airway Pressure therapy has evolved rapidly in the past 30 years. Evolved beyond the basic understanding of many of the people who prescribe it and many of those who dispense it. It fact, I heard a lecturer say that the technology is outpacing the science when it comes to treatment - scary thought. 

As things stand now, especially with how insurers are viewing diagnosis and treatment - everyone involved in this condition - clinicians, suppliers and patients are suffering. 

Calling for a "do-over" is not possible - but asking for a thoughtful examination of how this disease is diagnosed, treated and managed is - particularly as we here in the United States transition to a more patient-centered (read patient-financed) system of health care delivery. 

It is time for those patients, who have "come out on the other side", to help those who are struggling to examine current practices and the basis of that assessment recommend a care model that is efficient, cost-effective and sustainable going forward.