The End of Sleep Medicine (Part 4)

 "You've come a long way baby" Virginia Slims cigarette tagline ~ circa 1968

Nearly five years since I have put pen to paper (so to speak) regarding the "end" or goal of sleep medicine. During that time I have, mostly quietly watched, the (r)evolution of the field.  I thought to provide some reflections on a field of medicine that was my professional life for 10 years. I would like also to thank again those who were my teachers and colleagues in the pursuit of helping those with the chronic health condition - #obstructive sleep apnea (OSA) - #sleep disordered breathing.

I recently had the occasion to visit a #CVS near me and found much to my surprise (though not really) the following displays

My earliest memories of serving as the executive director of the American Sleep Apnea Association was attending as an exhibitor at the #American Thoracic Society's 2004 International Conference in Orlando Florida. It was there I first met many of the men and women who would be my mentors. It was there I also met many of the reps of the device manufacturers #Resmed, #Respironics (now part of #Phillips Healthcare), #DeVilbiss, and #Fisher &Paykel.

While I was setting up the booth I had two encounters that have stayed with me. First was a woman working with the company setting up the exhibit hall. She saw the sign and stopped to tell me how her husband has #OSA. She lay beside him in the bed with her hand on his chest to make sure he was still breathing. This was my first encounter with sleep apnea - the first of what would be many during my tenure.

The second conversation I had was with a vice president for sales with #ResMed the number 1 or 2 in sales of #Positive Airway Pressure devices or CPAP.  I remember the conversation as if it was yesterday and these two images from CVS moved it to the front of my mind.  #Ron Richards said to me in five years you will be able to get these devices over the counter. If they work for you keep it (and use it) and if not bring it back. Like his boss, #Peter Farrell was fond of saying the only way one of these can hurt you is if it falls on your foot.

It took longer than five years and there are likely still a couple of hoops to jump through when it comes with the device, but at least when it comes to the supplies they are available when needed.

A second meaningful experience was the first time I provided testimony before a committee of  #Medicare regarding the use of #home sleeping testing (HST) for the diagnosis of #obstructive sleep apnea. This led to the publication of an open letter in the #Journal of Clinical Sleep Medicine.  It would be some years before the sleep medicine community would accept that #HST would not decrease the number of people seeking treatment for OSA and there would always be cases where the use of #HST would not be indicated. 

One of the many companies vying for a portion of the #HST market was a company using a different modality of measuring the incidence of pausing in breathing. #Itamar does not use the limitation of airflow into the lungs, something the pulmonary sleep medicine physicians were less inclined to accept as an accurate measure of disease. Without getting into the relative merits of the two modalities. #Itamar's technology  Here is an explanation of how this modality works.

Perhaps more important an alternate diagnostic modality was this technique engaged a medical community that heretofore had been reluctant to engage - cardiologists.  It is well known that untreated OSA has significant consequences on the cardiovascular system.  As far back as 2008 in the journal Circulation, there was the recognition that untreated sleep-disordered breathing is a driver of heart disease.  Perhaps the Itamar WatchPat technology spoke to cardiologists in a way ResMed Apnealink did not.   The important point here is cardiologists seem to be more engaged than previously.

Another memory - a well-respected sleep medicine physician would frequently say diagnosing sleep apnea as was so easy the janitor at the hospital where she practiced could tell just from looking a people in the waiting room whether they were positive for OSA.

The third and final meaningful experience happened at a medical conference where the ASAA was an exhibitor.  Our booth happened to catty-corner to that of the Board of Registered Polysomnographic Technologist (BRPST) and as it happened members of the American College of Chest Physicians happened to be passing by. The College had recently considered developing a certificate program for an allied health position for sleep, something akin to the Diabetes educator.  It was something subsequently they did not pursue.  But it was something I believed would be vital especially as #HST became more the norm than the exception.  I had always felt that successful treatment meaning being completely adherence to whatever therapy or treatment worked for the OSA patient was more important than how the diagnosis was arrived at. I knew both the representatives of ACCP and BRPST, and so I brought them together suggesting that BRPST take on the certificate program for what then call the sleep educator. It took some time and some hard work, but eventually, the CCSH program was born.

Perhaps it is fitting this blog post, the last in a series is published today on the 40th anniversary of the publication in the journal  The Lancet of Colin Sullivan's seminal research study 

Thank you to all my teachers, colleagues, and most importantly the patients who made this experience one I will always cherish.

The End of Sleep Medicine - (Part 3)

To quote Whitney Houston: "I believe the children are our future."

The problem of sleep-disordered breathing is epidemic, like diabetes, heart disease, and obesity. I would argue and have elsewhere in this blog that all three of those conditions can be attributed to, at least in part, the chronic intermittent hypoxia that occurs when the person sleeping is not getting air into their lungs.

For the most frightening development (if you can call it that) is the increasing occurrence of the conditions listed above in children.

The prevalence of sleep-disordered breathing is 3 to 5 percent among all children - this is scary!

One of the many challenges for the field of sleep medicine seeking to address this problem in a cost effective manner.  Of course, in lab polysomnography or even a sleep study done at home would provide more data reducing the possibility of false positives or false negatives, but the number of children at risk is too great and the cost in either case is prohibitive.

A study published in the ATS Blue Journal provides evidence that use of oximetry aided by computer analysis alone was sufficient to screen children to determine who needed an intervention.

This could be at a significant savings (90 to 95%) over what the cost might otherwise be. As described in the study this machine learning enabled test can provide an inexpensive test to anyone who has access to a smart phone.

An increased awareness about the importance of sleep particularly among children coupled with the ability to screen for sleep-disordered breathing cost effectively should, I would say must, incorporate this into to all pediatric practice.

The field (calling all Clinical Sleep Health Educators) has its work cut out for it to disseminate the availability of this technology to help insure there will be children in our future.

Again to quote Whitney Houston:  "It is the greatest love of all."

On the road again - ATS in SFO

This my fourth international conference of the American Thoracic Society (ATS). The ATS meeting was the first medical conference I attended as executive director of the ASAA back in 2004.


The ASAA participates as an exhibitor at medical conferences like the ATS meeting as one of the ways we stay in touch with medical professional - in this case those involved in research on sleep disorders like sleep apnea. It is important that physicians, especially research doctors don't lose touch with the patients they are treating.


We are fortunate to patient volunteers interested in helping staff the booth and to speak with the doctors.


This meeting in particular provides an excellent opportunity to learn what is on the cutting edge of sleep apnea research. I will be pouring over the book of research abstracts for interesting posters to review.


Check back for updates over the next couple of days.