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improving and weight loss is crucial,” Dr. Marx remarks. “If a patient declines CPAP or cannot tolerate CPAP and wishes to try an oral appliance, make sure the patient is referred to a dentist who specializes in these appliances. A newer option is nasal resistance plugs, but I think the jury is still out on their effectiveness. Also, insurance coverage for some of these alternative treatments could be an issue.”

Document Co-morbid Conditions

Jason Marx, M.D., chief of Pulmonary, Critical Care, and Sleep Medicine at University of Maryland St. Joseph Medical Center

airway, blocked nasal passages or anatomical issues in the jaw or airway. Jason Marx, M.D., chief of Pulmonary, Critical Care, and Sleep Medicine at University of Maryland St. Joseph Medical Center, says, “About half of those who snore have sleep apnea; the only way to diagnose it is through a polysomnogram (sleep study). If the patient snores and has one other risk factor, or has daytime sleepiness, he or she is a candidate for a polysomnogram.” Insurers are driving more patients to unattended home sleep studies, rather than being evaluated overnight in a sleep

sleep study? Anita Naik, D.O., medical director of the Sleep Disorders Center, Harford Memorial Hospital and Northern Maryland Sleep Center, answers, “Those with significant comorbid conditions such as severe CVA, CHF, or lung disease, or those with suspected parasomnias. By contrast, a home study can be adequate for those with a high pre-test probability of sleep apnea, such as those with significant obesity, snoring or witnessed apneas.” Home sleep studies that are diagnostic for obstructive sleep apnea can be followed by a formal lab-based CPAP titration or the patient maybe set up

If the patient snores and has one other risk factor, or has daytime sleepiness, he or she is a candidate for a polysomnogram. —Jason Marx, M.D. center. Our sleep specialists note that home studies are appropriate for some patients, but not those with comorbid conditions or other disorders. Dr. Marx notes, “The big story is the transition from inpatient labs to home sleep studies, and some sleep labs are closing as a result. It’s not necessarily bad medicine, but it’s a new paradigm.” Who is not appropriate for a home

with an automatic CPAP device. These devices are about 80 to 90% effective. They are not effective at detecting and treating central sleep apnea, and are not indicated for patients with co-morbid diseases that could require additional therapies such as bi-level therapy or supplemental oxygen. “CPAP remains the gold standard for treatment, but oral appliances are

When ordering a lab-based sleep study, it is important for primary care physicians to document co-morbid diseases or a suspicion of other sleep disorders. A board-certified sleep doctor should always interpret the test to assure accuracy. Dr. Marx notes, “Sleep specialists can be called on to interpret the sleep study and, if appropriate, consult as well. It’s the primary care physician’s discretion whether they or we manage the patient. If you’re having trouble getting what you think the patient needs, contact a sleep specialist. We can work with the patient and insurer to select the appropriate diagnostic approach and treatment.”

Increased Anesthesia Risk Physicians should also be aware that anesthetics, including conscious sedation used in procedures such as a colonoscopy, make sleep apnea worse. “It’s like a stress test for sleep apnea,” Dr. Marx cautions. “Post-op patients are at higher risk for several days after their procedure. It’s important to indicate on your pre-op notes if a patient has or is at risk for sleep apnea.”

Insomnia Insomnia can be challenging to treat and typically requires both a medical and a psychological/behavioral approach. Dr. Naik recommends that the latter approach be tried first. “Good sleep hygiene is the first step.” Dr. Weinstein says, “Many cases of insomnia start with a personal problem like a divorce, but then become habitual. Physicians should ask about sleep as part of the history and physical. Review their medications to make sure they aren’t causing problems, and ask about alcohol

JULY/AUGUST 2013

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Maryland Physician Magazine July/August 2013 Issue