November 29, 2013

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....)

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