Sleep Apnea and Sleep Apnea Testing
Sleep Apnea is a period or multiple periods of disturbed sleep where the person stops breathing for prolonged periods of time. One consequence of sleep apnea is that a person can stop breathing and never start breathing again- which would cause sudden death. Sudden death, due to sleep apnea is a very preventable situation! With recent developments, the treatments are better than ever.
There are about 22 million Americans with sleep apnea. That's a lot of people who could suddenly stop breathing! In addition to sudden death, sleep apnea also causes high blood pressure, diabetes, and weight gain due to a chronic release of stress hormone for most of the night, prematurely aging every organ system in the body.
Many people with sleep apnea will get up to void 2 to 4 times per night. When they get up, their bladder is full! This full bladder feeling causes many peple to believe their condition is 'normal' since it's normal to void when your bladder is full. However, the bladder is full because the body has been releasing stress hormone, which in turn causes the release of diuretic hormone, which reduces the fluid load the heart will have to push against as the body 'fights' a condition similar to the rush of wild animals chasing it while a snake wraps around your neck. This 'life and death' struggle goes on for most of the night in people with sleep apnea.
Despite these huge risks, most people have never heard of sleep apnea, and are unaware of how dangerous it is when people do not get evaluated and treated in time. For example, in Santa Fe, during November 2011, a 43 year old man died from untreated sleep apnea.
On the bright side, through the past decade, our ability to evaluate sleep and to evaluate disturbed sleep has greatly improved. Over the past 2 years there have been about 3 generations of sleep related technology which have been developed and advanced. So, lets look at how to identify and then discuss some options to effectively treat sleep apnea.
How Did Adobe Get Involved Doing Sleep Studies
First, there's about 22 million people with sleep apnea in the U.S. Of that number, about two thirds have no idea that they have sleep apnea--they're just tired. We looked at the huge cost--$4,500 for a single sleep study--that's a huge price tag.
We searched around, and found the ARES system which is as effective as an overnight sleep study and only cost about $220 to perform. There was no national or regional company that performed overnight sleep studies in home, at the time.
About this time last year, a national company appeared on the scene. They provided the ARES device through UPS or via the U.S. Mail, and did so for $285 per test. For us, this was a service we provided to the community. Now that a national firm was able to provide the tests for about the same charge, we closed down our own sleep study program in October 2012.
We diagnosed and treated many people over a 1 year timeframe, but since we already perfom so many other services, we took the October 2012 as an opportunity to have the 'big players' perform the studies.
We still order the tests, but now we refer the patients for either the CPAP treatment device, or the Mandibular Advancement Splint (MAS). By the way, Dr Robert Wartel, DDS provides the best MAS in the state--and his office is just next door to our office. more on the MAS below.
Sleep Study Labs (for Over Night Sleep Studies)
For over a decade, the 'standard' sleep study was conducted in a 'sleep lab'. The lab looks like a hotel room with a window and monitor cameras for staff to watch the person while they sleep. Typically the person is connected to: multiple scalp wires to read brain wave activity and sleep level; multiple EKG wires to evaluate heart rate and pattern while asleep; limb lead lines to monitor leg and arm movements while asleep; and a finger oxygen sensor lead wire.
Typically, the person has a two day study since the environment is foreign and there are multiple wires attached which distract most people; finally most people are not comfortable sleeping in the foreign environment of a sleep lab. There are usually two to three staff members present as the person will need to be up 3 to 4 times per night to get up to empty their bladder, and usually one or more staff accompany the person for safety.
Most sleep lab studies cost the patient and the insurer about $4,500 for the study. In Florida, the sleep labs are charging about $9,500 for the same service.
Overnight Sleep Studies at Home
Would you prefer to do a sleep study, in the privacy of your own home, without any wires? Once we make such a decision, some wonderful things happen when we do a home sleep study:
1. There are no longer 2 or 3 people there with you, all night long, 'watching' you;
2. You get to sleep in your own bed!
3. The latest technology (ARES) is a completely wireless system which does everything the wired systems perform;
4. Because of the above conditions, 99% of the time a single night is all that is needed to do the study!
So, how wireless? The ARES home sleep study is accepted as an 'approved' and a 'proper' device for sleep study research by all professional organizations and insurers, including Medicare and Medicaid. The ARES device is the least 'wired' of all monitoring devices and has all of its' sensors placed in a soft databank across the forehead (look at the photos below), which are held in place with a strap (like a divers mask strap). The only other attachment is a nasal canula placed just inside the nostrils, like one would wear when receiving oxygen through a nasal canula- this allows us to know whether a person is breathing through their nose or through their mouth. In short, the ARES device looks like something out of Star Wars or Star Trek.
There are a few other approved home sleep study devices, but none more accurate, and none that are as wireless and as compact as the ARES device.
Between what the person pays and what the insurer pays, the ARES costs $285 for a one night study (which means we can do 15 studies, in the privacy of people's own homes with very accurate data, for less than a single 'sleep lab' study that would run over 2 days (15 tests x $285=$4,275, which is $225 less than the single 'sleep lab' cost of $4,500)! If we use the Florida numbers ($9,500) we can do 33 home sleep studies and still cost less for the person and the insurer!
So, has anyone weighed in on how 'good' the home sleep studies are? One of the largest insurers in the nation- United Health, has a policy whereby they will not pay for a standard 'sleep lab' study when there are professionals offering 'home sleep studies' in a community area (of about 100 square miles). The folks at United Health understand: why pay $4,500 for a single 'sleep lab' test when home sleep studies can be done on 15 people, in the privacy of their own homes, and with equal accuracy for less overall cost?
The home sleep study is more comfortable and private for the person. And, from a cost standpoint for the insurer, such as United, and for the patient's much lower copay, there's a combined coat savings of $63,225 for 15 tests! Home sleep studies are a very smart choice for both parties!
ARES Home Sleep Study Device
The Apnea Risk Evaluation System (ARES) Device is an effective wireless system for conducting scientific evaluations of sleep and sleep distress in the privacy of your own home. On both March 13th 2008 and March 9th 2009 the Centers for Medicare and Medicaid Services determined that coverage for treatment of sleep apnea testing could be diagnosed using a home sleep study.
Insurers have followed the Medicare and Medicaid guidelines and fully support home sleep studies. To further confirm accuracy, your study will be evaluated by our Medical Director at our Sleep Center, as well as by a second Board Certified Sleep Specialist Physician, licensed in New Mexico. Our Sleep Specialist has reviewed tens of thousands of sleep studies.
Patient Screenings: must be conducted face-to-face with clinical evaluation prior to the ordering and scheduling of a sleep study. A validated sleep study questionaire will be completed to confirm the degree of symptoms related to sleep apnea.
Home Sleep Study Testing: we sign and send an order for the ARES sleep study. The equipment is dispensed by the National Sleep Center. The patient has the ARES device sent to their home by UPS. the person watches a DVD or internet program, then they properly apply the device and undergo the sleep study in the privacy of their home. The ARES device self terminates the study after 6 hours of recording. The patient then returns the device to the National Sleep Center via UPS.
Consultation: Generally, within 72 hours we receive our detailed 2 page report from the sleep study specialist.
Follow-up and Compliance: happens when we schedule your initial follow-up visit to review your results. The findings will be reviewed and appropriate therapies discussed for the individual's particular condition. If the individual requires variable CPAP treatment, an initial visit is scheduled for 1 to 2 weeks after treatment starts. A second visit for complicance and questions is scheduled for 30 days, and then every 90 days we follow-up with each patient to insure all is going along smoothly. If the person wants to use a MAS, we refer them to Dr Wartel for evaluation and treatment.
Insurance Coverage: Insurers require periodic follow-up, such as we provide. The insurers have thousands of dollars invested in treatment, as well as a sincere concern for the patient's welfare. The insurers will halt payment coverage for a variable CPAP device for treatment if the person is not using the treatment device at least 4 hours per night on 70% of the nights evaluated, during any 30 day consecutive treatment period. The sincere concern is that the technology to prevent sudden death only works when it's used every night.
Denial is unfortunately a choice in 'treatment' for many people, whereby a person uses massive amounts of psychological energy to deceive themself into thinking that they do not actually have sleep apnea, and therefore do not require any treatment. Other people will die from sudden death, others will develop high blood pressure, diabetes, gain weight, and prematurely age every organ system in their bodies, but not those people who are in denial! Denial is not an effective form of treatment.
Surgery can be performed which cuts out most of the soft palate, tonsils and adenoids. The idea is that by removing the 'excess' tissue in the throat, a large passage can sometimes be made to prevent airway obstruction. The procedure's are both painful, and may not resolve the condition. For some people the surgeries have worked, but even those happy with the outcome advise considering other treatments due to pain, infection potential, scar tissue formation, and other risks. Also, anyone who has their tonsils removed increases their lifetime risk for colon cancer by about 30%.
Oral Applicance or Mandibular Advancement Splint (MAS)Therapy is the making and application of a standard or custom made appliance which fits inside the mouth (splints or pushes forward the lower jaw). The 'standard' devices are large, bulky and cost about $600 to $800 each. The 'custom' appliances are about one third the size of the 'standard' devices. A thorough work-up is required for custom devices, rising the cost to about $4,500. Both devices work by slightly moving the lower jaw forward about one half to one inch. Some insurers cover the cost of the devices, others do not.
CPAP (Continuous Positive Airway Pressure) Devices are the 'standard' most often used to treat Sleep Apnea. The devices are universially covered by insurers and much has changed in how CPAP's work and function over the past 3 years.
Some CPAP history: Back in the 'bad old days', a CPAP was a large as a small table; the devices were so loud they could be heard 200 feet away- and were obnoxious; the masks were made from a hard plastic which was worn tightly (like Darth Vader); and worst of all there was only one setting- that way just over half the night the mask blew off a person's face due to too much pressure, and the rest of the night the airway collapsed due to not enough pressure. The old CPAP devices are affectionately referred to as 'science fiction'- there wasn't much 'science' to them and there were false claims as to how they worked (fiction). Caution: there are still providers prescribing the 'old' CPAP devices, and there are Durable Equipment providers eager to provide older, ineffective treatment devices.
Current times: The CPAP is now as small as a box of tissue paper, and half of that is a humidifier; the CPAP unit, when connected to the patient, is completely silent; the masks are made from a very soft silicon (or cotton material for those with allergy), and come in many shapes, sizes, and forms for best personal fit; finally the new CPAP's have a 'variable function' (Variable CPAP or VPAP) with a snazzy computer chip which directs the device only to produce the required amount of positive airway pressure required for the exact moment to keep the airway open: no more, and no less. Each and every second, the variable CPAP readjusts the airway pressure- now we're talking science!
The results with the newest generation of variable CPAP devices are that with the newer, more advanced CPAP, a person can lay down, and instead of tossing and turning for 30-45 minutes, they're asleep in under 2 minutes. Instead of getting up to void 2 to 4 times a night, a person can sleep through the entire night and feel completely well rested the next morning. In short, the newer variable CPAP's give you your life back, and they let you sleep like you did decades ago!
From a conclusive study published in the journal CHEST, December 2011, page 1511, Over the past 6 months the CHEST study, as well as several other studies have confirmed that for mild to moderate sleep apnea, the splints work, though not as effectively as CPAP for moderate sleep apnea. For moderate to severe sleep apnea, the consistent finding is that CPAP is the safest and most effect choice with a huge benefit of CPAP over the use of splints.
A more recent study, pullished in the American Journal of respiratory Critical Care Medicine, April 15th 2013 cited the MAS as more effective because the slints are, on average, worn 6.5 hours/night versus the CPAP at 5.2 hours/night. More use= more safety. If a device is not used, it's 100% ineffective for the time the CPAP is not used.
The conclusion of this and other recent reports: treatment is more about compliance. So, which treatment for sleep apnea would you prefer to use?
Incident hypertension with Sleep Apnea
From the British Medical Journal, May 23rd, 2012: Treatment with continuous positive airway pressure (CPAP) lessened the risk in severely affected patients for premature death from heart attack or stroke.
Numerous studies have shown that a strong releationship between obstructive sleep apnea (OSA) and hypertension (high blood pressure- AKA HBP) has existed for decades. In two related studies from Spain, investigators proved, over a 12 year follow-up period, that of 1,579 patients with OSA, that those with OSA had a significantly greater risk for HBP and subsequent preventable death from cardiac causes versus 1,889 patients without OSA.
A subsequent 4 year study of OSA in Spain revealed that OSA was most significant in those with daytime sleepiness. While that sounds significant and direct- most people with daytime sleepiness will deny they have such a condition. Most people convince themselves that feelings of fatigue and sleepiness are their 'normal' and they are not 'excessively' sleepier from their, 'normal' state. So, while this study seems to identify a group at higher risk for HBP and premature death, due to denial, these factors will be extremely difficult to objectively identify.
For example, one patient interview conducted for OSA here in Santa Fe had the patient deny daytime sleepiness. The next sentence was not completed by the provider as the patient began snoring mid question about their problem, which they'd denied existed.
Research is interesting and provides light in an otherwise dark universe. However, reality proves that certain 'testing' and 'evaluations' may be grossly lacking in accuracy due to human denial of actual thoughts and behaviors. Empericism- that is, the objective evaluation of that of which is directly before us, which is in a obvious, objective, viewable state, can beat out research.