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.

Sleep, Sleep Apnea and the Ides of March.

The month of March has become, officially or unofficially, the month dedicated to sleep. It makes sense. For a long time and coincident with the vernal equinox we collectively (except for Arizona) adjust our clocks forward an hour to allow for an additional "hour" of daylight at the end of the work day. This adjustment occurs when we are, or should be, sleeping.

Our colleagues at the National Sleep Foundation designated the week before the time change National Sleep Awareness Week(r) and use that time to release an annual poll regarding a sleep issue.

This year, unlike previous years, there were several other important information releases during the month that bear mentioning.

On March 1st, the American Thoracic Society released a long awaited report on research priorities for ambulatory management of adults with obstructive sleep apnea. What is significant is that collaborating on the report are three of the principal medical societies responsibility for diagnosis and treatment of sleep apnea, plus the European Respiratory Society. Having everyone rowing in the same direction can only help improve the care of those with sleep apnea - here in the United States and Europe.

On March 7th, the Centers for Disease Control and Prevention published in their Morbidity and Mortality Week Report the analysis of data collected as a part of the "sleep module" from 12 states in their Behavioral Risk Factor Surveillance System (BRFSS). The addition of this set of questions to the BRFSS was due in large measure to lobbying the U.S. Congress to pay attention to sleep.  A portion of the funding granted by Congress was used to pay the expenses of the National Sleep Awareness Roundtable. 2009 was the first time the module was included and as the graphic above indicates that those getting less than 7 hours of sleep a night have a higher likelihood of snoring, unintentionally falling asleep and nodding off (!) while driving.

The watershed event of the month occurred on March 15th, when the Institute of Medicine released their report on the leading health indicators for Healthy People 2020. The IOM, at the request of the US Department of Health and Human Services distilled the nearly 600 objectives included in Healthy People 2020 down to the 24 most important. Included among the 24 was one of the four from the Sleep Health topic -  Increase the proportion of adults who get sufficient sleep. It was already significant that sleep now had its own "topic" under Healthy People. On top of that, to be included as one of the leading health indicator is a great leap forward in awareness.

March is about sleep and this year the needle moved on the importance of sleep. Now our job is not to let them forget about it the rest of the year.

Here is a link to a news report our of Atlanta concerning the death of young man while undergoing a sleep study at the sleep lab at Emory University. The circumstances around the death remain a mystery. While we sleep, we are at our most vulnerable. Incidences like this one might cause someone already weary not to place their trust in those who watch them sleep. The sooner Emory can provide an explanation the better.

Family, Emory, At Odds Over Man's Death During Sleep Study - 11Alive.com WXIA Atlanta, GA

FYI

After 10 years in the same location, downtown Washington, DC the American Sleep Apnea Association is heading uptown... Takoma to be exact.

The ASAA takes up residence at the Takoma Metro Centre,

6856 Eastern Avenue, NW

Suite 203,

Washington, DC 20012

effective August 1st.

The telephone and fax numbers will remain the same.

Exciting times at the ASAA... stay tuned!

Looking ahead... September & October

September is promising to be a busy month for me. The updating of the video will be in pre-production, there is the script to review and rewrite, the location for the sleep lab sequences, the actors/participants. That all by itself would keep me plenty busy.

The American Academy of Otolaryngology - Head and Neck Surgery has its annual meeting in Washington, DC and I have made arrangements to meet with Dr. Ed Weaver who leads their sleep doctor group. I am hoping to get to the exhibit hall and review a the program of educational session to see who is talking about surgery and sleep apnea.

Later that same week I have meetings scheduled with the leaders of other organizations located in DC. A successful outcome in both meetings would be raising the visibility of the association and finding ways to partner with them to mutually advance our causes.

The week closes with a trip to Pittsburgh and the meeting of one of the councils of the American Trucking Association. Truck drivers are in the news these days and research shows they are at a heightened risk of developing sleep apnea. The trucking firm Schneider National has taken a pro-active approach to the problem by screening employees and providing for treatment.

The ASAA has the opportunity to make available our resources ie, patient education materials and the A.W.A.K.E. Network (and apneasupport.org) to the trucking company safety directors to help them help their employees at risk.

There is more travel in October... San Francisco for the American Society of Anesthesiology meeting and then Chicago for the American College of Chest Physicians meeting. I will be reporting on those when I am there.

I'll be back.

News and promises

I have some exciting news to share with all those who count on the American Sleep Apnea Association to provide unbiased information on diagnosis and treatment on OSA... we have received a generous grant to remake our 1994 video "What is Sleep Apnea?" We are currently interviewing production companies and hope to begin production in September. It should be available just time for holiday gift-giving.

Updating the video has been on my list since I got to the association three and a half years ago - yeah!

The other important news of the day concerns our online support group - http://www.apneasupport.org/. Due to serious limitations with the current web hosting company's capacity to handle the increasing traffic to the site, the site co-adminstrator had to make an emergency move to a new host.

He handled the transfer of the incredible amount of wisdom accumulated over the past two year from contributors to the forum with the flawless grace of an NBA All Star shooting from the outside with only seconds to play... thank you Mike.

The new home of the Forum, which is on downtownhost.com, is now on a dedicated server and is faster than greased lightening. It is able to accommodate a much higher level of traffic without the usual degradation in speed. Recent statistics already show an increase in visitors, pageviews and new subscribers. If you have not been in a while or not at all... check it out, you won't be disappointed in what you can learn there.

On a side note... we get tons of email at our main email address - asaa@sleepapnea.org, sadly much of it spam, but that is the price of having your email address out there for folks to access with questions and comments. Looking at it last week, along with the usual inquiries, there was a message from a anesthesiologist in Kuwait looking for ways to work with the ASAA to help his patients, a jounalism student from Denmark doing research on sleep apnea in America looking for an expert sleep researcher to help him, and a former A.W.A.K.E. coordnator now residing in Singapore who is interested in setting up an A.W.A.K.E. support group there. One word - wow!

Now the promise, since my friend and colleague Dr. Breus has added me to his blogroll and I suspect that there may be others (thank you Michael and thank you everyone else)... I will commit to being more intentional about writing in this space on a regular basis to report on my doings and the work of the association.

These are exciting and very busy times and I am pleased to share our successes and challenges with all those who take the time to read this.

I'll be back.