A2Zzz Volume 22 Number 1

March 2013 | Volume 22 | Number 1



AAST 35th Anniversary Meeting Preview



Sleep-Disordered Breathing and Diabetic Retinopathy



It’s All in The Genes



Patient and Individual Safety in the Sleep Center



The Impact of Out of Center Sleep Testing

A Publication of the American Association of Sleep Technologists

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35TH ANNIVERSARY MEETING AMERICAN ASSOCIATION OF SLEEP TECHNOLOGISTS

Baltimore

JUNE 2–4, 2013

REGISTER NOW AT WWW.AASTWEB.ORG

American Association Sleep Technologists

A AST of

®

4

FROM THE EDITOR

MARCH 2013 | VOLUME 22 NUMBER 1

By Rita Brooks, MED, RST, RPSGT, REEG/EPT adly, we have lost another sleep medicine pioneer. Dr. Peter Hauri, always a technologist advocate and well known for this as well as his Current Concepts volume The Sleep Disorders passed away on January 31, 2013. His obituary is included in this issue of A2Zzz.

S

TABLE OF CONTENTS From the President...........................................6

As we move forward into new uncharted territory in the healthcare and sleep technology arenas, I would like to remind RITA BROOKS, you that you can begin to prepare for MED, RST, RPSGT, changes in sleep technology by signing REEG/EPT up for the Advances in Sleep Technology: The New Sleep Center Model Course March 23-24 in Darien, Ill.

In Memoriam....................................................7 AAST 35th Anniversary Meeting Preview.........9 AAST Spring Course Preview........................ 10 Neurodiagnostics and Sleep Science Program........................................... 11

This issue of A2Zzz includes some outstanding educational articles for your reading pleasure. Mark D. Eley once again shares with us how health informatics affects and influences the healthcare environment. In this issue Mark points out safety considerations from a physical as well as an information technology (IT) perspective.

Continuing Education Credit Offering.......... 13 AAST CEC Evaluation Form........................... 14 Sleep-Disordered Breathing and Diabetic Retinopathy................................ 15-17

Regina Patrick discusses retinopathy and its possible relationships with diabetes and obstructive sleep apnea (OSA). A thorough description of the physiology of retinopathy and diabetes is provided along with an informative review of the research examining the relationships between these disorders.

It’s All in The Genes.................................18-20 Patient and Individual Safety in the Sleep Center............................................. 21-24

Joanne Hebding provides us with a view of the possible effects of environmental and physical stress on the disease processes and how genetics may play a role in the manifestation of excessive sleepiness and narcolepsy in different patients.

Legal Notes: The Impact of Out of Center Sleep Testing................................25-26 Technical Corner: The New HypopneaRule..........................................27-28

In this issue, the technical corner by Dr. Richard S. Rosenberg, the AAST’s Educational Development Coordinator, discusses the evolution of hypopnea scoring over time and the new hypopnea scoring rule. His review includes an interesting discussion of the development of the hypopnea rule for the latest revision of the AASM Scoring Manual, V 2.0.

Why Did My CPAP Beat Me Up?..............29-31 In the Moonlight............................................ 33 AAST Educational/Technical Product Order Form................................................34-35

Once again, I’d like to remind you to renew your AAST membership for 2013. A new and valuable member benefit for 2013 is free access to 2 new online learning modules, with continuing education credits (CECs), per month. These modules focus on timely topics and strive to advance the knowledge of experienced technologists. As we move forward into the new landscape, your membership organization is working to provide relevant education that will prepare you for changes affecting the field of sleep technology.

Sleep Well, Rita Brooks

AAST Promotional Item Order Form............. 36 Certification Update.......................................37

September

2010 | Volume

19 | Number

3

Insomnia al Loss with le Neuron Upper Apnea and ctive Sleep Oxide, Obstru mation Facilities for Sleep Airway Inflam Techniques Strategy and Management

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A2 Zzz 22.1 | March 2013

Submit an original article for publication in A2Zzz. See page 6 for details.

5

OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION OF SLEEP TECHNOLOGISTS (AAST)

ABOUT A2Zzz

A2Zzz is published quarterly by the American Association of Sleep Technologists (AAST), 2510 North Frontage Road, Darien, IL 60561.

Postage paid at Eau Claire, Wisconsin.

Advertising: Advertising is available in A2Zzz. Please contact the AAST national office for information concerning A2Zzz rates and policies, or find more details online at www.aastweb.org.

Learning Objectives: Readers of A2Zzz should be able to do the following: • Analyze articles for information that improves their understanding of sleep, sleep disorders, sleep studies and treatment options • Interpret this information to determine how it relates to the practice of sleep technology • Decide how this information can improve the techniques and procedures that are used to evaluate sleep disorders patients and treatments • Apply this knowledge in the practice of sleep technology

Disclaimer: The statements and opinions contained in articles and editorials in this magazine are solely those of the authors thereof and not of the American Association of Sleep Technologists (AAST); the American Academy of Sleep Medicine (AASM), which provides management services for the AAST; or of either organization’s officers, regents, members or employees. The appearance of products and services, and statements contained in advertisements, are the sole responsibility of the advertisers, including any descriptions of effectiveness, quality or safety. The Editor; Managing Editor; AAST; AASM; and each organization’s officers, regents, members and employees disclaim all responsibility for any injury to persons or property resulting from any ideas, products or services referred to in articles or advertisements in this magazine.

Annual Subscription Rates: Subscription to A2Zzz is included as a member benefit of the AAST. Subscription rates (non-members and institutions) for 2013, Volume 20: $60, outside U.S. $140.

Submissions: Original articles submitted by AAST members and by invited authors will be considered for publication. Published articles become the permanent property of the AAST. Change of Address: Changes of address should be submitted four to six weeks in advance of the change to ensure uninterrupted service.

Members of the AAST can edit their address online when they log in at www.aastweb.org. Subscribers also can send to the AAST national office their new address, the effective date of change and a copy of the current mailing label showing the old address.

Postmaster: Send change of address to AAST, 2510 North Frontage Road, Darien, IL 60561.

Missing Issue Claims: Claims for missing issues must be submitted within 60 days of the publication date by fax to the AAST at (630) 737-9788 or by e-mail to A2Zzz@aastweb.org Permission to Use and Reproduce: A2Zzz is published quarterly by the AAST, all rights reserved. Permission to copy or republish A2Zzz material is limited by restrictions. Visit www.aastweb.org to view the full A2Zzz permissions and use policy.

Reprints: Contact the AAST national office for orders of 100 reprints or more.

Mission: To promote and advance the sleep technology profession through the continued development of educational, technical and clinical excellence in sleep disorders.

Vision: To preserve the autonomy and future of the sleep technology profession by providing educational and professional pathways with innovative approaches that promote professional growth and development Purpose: To provide a voice for the professionals who ensure the safe and accurate assessment and treatment of sleep disorders 2510 North Frontage Road Darien, IL 60561 Phone: (630) 737-9704 Fax: (630) 737-9788 E-mail: A2Zzz@aastweb.org Web: http://www.aastweb.org © 2013 American Association of Sleep Technologists

SUBMIT AN ARTICLE TO A2Zzz

Share your expertise with colleagues in the profession of sleep technology by submitting an original article to A2Zzz. Read the A2Zzz Writer’s Guidelines at http://www.aastweb.org/A2ZzzGenInfo.aspx. To propose an article topic or to get more information, send an e-mail to A2Zzz@aastweb.org.

CONTRIBUTORS EDITOR

Rita Brooks, MED, RST, RPSGT, REEG/EPT

MANAGING EDITOR Lynn Celmer

SENIOR WRITERS

Regina Patrick, RST, RPSGT

CONTRIBUTING WRITERS

Nisar Ashraf, BSRC, CRT-SDS, RPSGT, RST Mark D. Eley, MS, RST, RPSGT, RRT-NPS, RPFT Cameron D. Harris, RPSGT Joanne Hebding, RST, RPSGT Mary Ellen Wells, MS, RPSGT, R.EEG T., R.NCS T.

SPECIAL FEATURES Jayme Matchinski, Esq. Richard S. Rosenberg, PhD

CEC ARTICLE REVIEW PANEL

Karen Allen, RPSGT, CRT Eric Bell, PsyD Richard Bonato, PhD, MA, RST, RPSGT Rita Brooks, RST, RPSGT Todd Eiken, RPSGT David Gregory, RST, RPSGT Henry Johns, RPSGT, CRT Douglas Kirsch, MD Jennifer May, RST, RPSGT David Wolfe, MSEd, RST, RPSGT, RT

A2Zzz publishes articles that relate to the profession of sleep technology and informs members about recent and upcoming activities of the American Association of Sleep Technologists (AAST).

A2 Zzz 22.1 | March 2013

6

FROM THE PRESIDENT

By Melinda Trimble, RST, RPSGT, LRCP s President of the AAST I felt it was vital that I have a vision of my organization’s future leadership team.

A

Over the past decade, sleep medicine has seen significant growth in terms of academic understanding of sleep disorders and the use of diagnostic testing as a tool to improve patient outcomes. Sleep centers, which have AAST PRESIDENT been the primary forum for diagnosis MELINDA TRIMBLE, and treatment of sleep disorders over RST, RPSGT, LRCP this time period, are facing increasing pressure in terms of number of sleep labs and alternatives to in lab testing (out of center sleep testing). As president of the AAST I have been asked to speak to the “Future of Sleep” several times over the past two years. My personal belief is that “our people are our future.” I feel that is true for our respective companies as well as the AAST. So how does one develop future leadership? The AAST board of directors knows leadership development is important to the growth of our profession. One of the most important actions we can take to start our leadership development is to have a plan.

This past fall the AAST hosted our first leadership development conference. Members of the AAST committees, along with the AAST board of directors, were brought together for training, discussion and group leadership development. I believe it is important to identify and develop those individuals who will lead the critical functions of our organization, and this was a first step in that direction.

ever more so, tomorrow. I know it will not be easy but I believe it is vital to the long-term health of our organization. The AAST is committed to the preservation of our organization and our profession.

If you are a new or returning member of the AAST I would like to personally thank you for your membership; it is vital for the continued support and future growth of our profession. If you are not currently a member, I would ask you to please consider becoming a member or renewing your AAST membership.

With your membership dues you help support the work being done to preserve our profession.

It has not always been easy to be the AAST president. There are those who will tell you there is no value to membership. I would say it takes courage and strength to stand up for what you believe in. I believe in the work we are doing within the AAST to prepare our leaders and members for the future and preserve the sleep technology profession. Each and every member is important, and I urge you to participate in your professional organization. As a membership organization the AAST needs its members to stand together to craft the future of sleep technology.

Until we meet again,

Melinda Trimble AAST President

Today, I would ask you to consider your potential role in AAST leadership. I have been told there is almost universal agreement that leadership is a skill that can be learned. I personally feel that leadership is a fire that can burn brightly in all of us if we can find that one thing that starts the flame or that one person who believes in us. Pure leadership means showing the way for others, either by example or by promoting a new direction.

I hope I have been able to do both during my two-year term of office. As AAST president I have tried to take a proactive approach to identifying individuals who have the potential to fill our leadership roles, and to reach out to those who could be the leaders to carry our organization’s mission into the future. I hope I have sparked a few flames.

Now that we have started the process of identifying our future leadership our work has just begun. Now we must get to work developing our potential leaders. We must equip them with skills and the capabilities needed to be effective leaders today and

A2 Zzz 22.1 | March 2013

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IN MEMORIAM: PETER HAURI, PH.D

By Cameron D. Harris, RPSGT

P

eter J. Hauri, Ph.D., a pioneer of sleep medicine, passed away in Rochester, Minn. on January 31, 2013 at the age of 79. Obituaries for Dr. Hauri have been published in the New York Times, Boston Globe and elsewhere. Dr. Hauri was a kind and humble person who always insisted that he be addressed as “Peter.” He had a special knack for communicating and explaining concepts in a way that his audience would not only understand, but also enjoy. Throughout his career he played pivotal roles in the evolution of sleep medicine and had a special appreciation for the importance of sleep technologists.

Born in Switzerland, Peter began his career as a teacher at the International Children’s Village in Pestalozzi. A visiting group of American students was so impressed with his teaching ability that they convinced him to come and study at North Central College near Chicago. He eventually pursued a doctorate in psychology at the University of Chicago where he sought an assistantship with Alan Rechtschaffen, Ph.D. When Peter arrived for an interview, he found Dr. Rechtschaffen in the midst of repairing some equipment. Having learned how to solder in the Swiss Army Signal Corps, Peter impressed Dr. Rechtschaffen by completing the repairs and became an assistant in the sleep laboratory where he developed skills and interest in sleep research and polysomnography. Subsequently Peter served a clinical psychology internship with Rosalind Cartwright, Ph.D. and thus began his career of blending research with clinical treatment of sleep disorders.

Dr. Hauri practiced briefly as a clinical psychologist in California before working with David R. Hawkins, M.D. at the University of Virginia where he completed the research leading to the description of alpha-delta sleep. In 1971 he was hired to run the sleep research laboratory at Dartmouth College, which Peter developed into one of the first clinical sleep disorders centers. While at Dartmouth, Peter earned acclaim for his practical behavioral approach to treatment of insomnia and authored the well-read Current Concepts volume titled The Sleep Disorders in which he introduced the concept of sleep hygiene.

The “Gray Book”, as it was called, was a concise and cogent monograph that became the de facto primer for technologists and physicians entering the field of sleep medicine. After a second addition was published in 1992, Peter granted the Association of Polysomnographic Technologists (APT, now known as the American Association of Sleep Technologists) permission to reprint and distribute it. Making one final move to Minnesota in 1988, Peter joined the Mayo Clinic where he served as co-director of the Sleep Disorders Center until retirement in 2000. During his time in Minnesota, Peter worked with Shirley Linde to complete his classic book on management of insomnia, No More Sleepless Nights, which remains a best seller and an invaluable resource for clinician and patient alike.

Photo reprinted with permission of the Mayo Clinic Peter Hauri was a leader in the development of Sleep Medicine. He was an early member of the Association for the Psychophysiological Study of Sleep and served as executive secretary from 1982 to 1984 when the organization changed its name to the Sleep Research Society (SRS). As interest in the clinical aspects of sleep disorders grew, Peter helped create the Association of Sleep Disorders Centers, which eventually evolved into the American Academy of Sleep Medicine (AASM). His leadership in clinical sleep medicine continued as he helped develop an examination for clinical polysomnographers. Later, Peter was a member of the Nosology Committee that created the International Classification of Sleep Disorders in 1979 and served as chair of the task force that revised it in 2005. His contributions have been recognized by the American Academy of Sleep Medicine with the Nathaniel Kleitman Award in 1989 and the National Sleep Foundation with the Excellence in Insomnia Research and Education Award in 2011.

Peter often identified himself as a technologist relating the many nights he had spent preparing subjects and recording polysomnograms to gather data for his research. When the APT created the American Board of Registered Polysomnographic Technologists (now the BRPT) to administer an examination for sleep technologists, Peter participated several times as an examiner including during the first administration in 1979. A perspective of Dr. Hauri’s career can be gained by listening to the Conversations with our Founders interview on the SRS web site. 

A2 Zzz 22.1 | March 2013

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AAST 35TH ANNIVERSARY MEETING PREVIEW

Registration is open for the American Association of Sleep Technologists (AAST) 35th Anniversary Meeting, which will take place from Sunday, June 2, through Tuesday, June 4, 2013, at the Hilton Baltimore Hotel in Baltimore, Md. Attendees will be able to stay current with the latest trends and developments in sleep technology while earning up to 19.75 continuing education credits (CECs).

The AAST 35th Anniversary Meeting has been redesigned with the busy sleep technologist in mind. The program has been condensed into an intensive, three-day meeting that will cover topics from out of center sleep testing (OCST) to social media’s impact on the lab, to the American Academy of Sleep Medicine (AASM) scoring manual changes. The foremost authorities in sleep medicine and sleep technology will present workshops, symposia and discussion groups at the meeting as well. Attendees will still have access to the SLEEP 2013 vendor hall and the SLEEP 2013 Plenary Session and new, exciting sessions including oral presentations of the latest research and case reports.

The premier educational event in sleep technology will offer eight, hour long courses on the opening day. Course registrants can choose from these educational opportunities: The Changing Face of Sleep Technology; OCST and Its Impact on Sleep Technologists; CPAP Adherence/Compliance; The Impact of the Affordable Care Act on Sleep Medicine; Optimizing Sleep Apnea Screening and Preoperative Management in a Community Hospital/Occupational Sleep Medicine; Recent Developments in Cognitive Behavioral Therapy for Insomnia; Review of New Technologies and Pro/Con Debate: OCST/ Auto-PAP. The second day of the meeting starts with plenary sessions on the Evolution of Insomnia: Patient to Population, Primary to Comorbid, Laboratory to Clinic and Pathophysiology to Therapeutics and NIH and Advances in Sleep Research: Past, Present and Future Opportunities. The day will also include oral

presentations, a course on the new scoring rules, case example presentations on Rapid Record Review and the AAST General Membership, Awards and Anniversary Celebration.

Day three wraps up with case example presentations on Comorbid Case Studies and Complex Conditions; a panel discussion on Circadian Rhythm/Genetics/Fatigue/Sleep Deprivation; a debate on Hypoxia or Arousals and a course on In-Bound and Out-Bound Marketing in Your Sleep Center.

Expertise will be shared by invited lecturers Kevin Asp, RPSGT, CRT; Alexandre Abreu, MD; Gregory Belenky, MD; Michael Bonnet, PhD; Rita Brooks, MED., RST, RPSGT, REEGT/ EPT; Carolyn Campo, MA, RRT, RPSGT, RST; Robert Geck, MD; Rod Hughes, PhD; Laura Linley, RST, RPSGT, CRT; Jayme Matchinski, JD; Gokhan Mutlu, MD; Sairam Parthasrathy, MD; Robert Rosser, MD; Melinda Trimble, RST, RPSGT, LRCP and Nancy Wesenstein, PhD. An advanced registration discount is available for the AAST 35th Anniversary Meeting until April 17, 2013. Pre-registration will continue until May 20, after which registration will only be available on site beginning at 6:30 a.m. on Saturday, June 1.

While in town for the conference take a short walk to visit the many leading tourist attractions, including Baltimore’s famous Inner Harbor, M&T Stadium – home of the Super Bowl champion Baltimore Ravens, the University of Maryland and Johns Hopkins University or catch a Baltimore Orioles game at Camden Yards, one of the most beautiful stadiums in baseball.

The hotel is also ideally located near some of Baltimore’s famous neighborhoods such as Mt. Vernon, Federal Hill and Fells Point for local shopping, great dining and theater.

Register today for the AAST 35th Anniversary Meeting! Visit www.aastweb.org to download the preliminary program or to register online. 

A2 Zzz 22.1 | March 2013

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AAST SPRING COURSE PREVIEW

Register today for the AAST Spring Course, Advances in Sleep Technology: The New Sleep Center Model, which will take place March 23-24, 2013, at the AAST National Office in Darien, Ill. This two-day course focuses on the technologist’s perspective to the shifting sleep environment – an expert faculty will address these changes and the impact they have on the role of the sleep technologist and patient care strategies. Attendees will have the opportunity to earn up to 12 hours of continuing education credits (CECs). An application has been submitted to the American Association for Respiratory Care (AARC) for Continuing Respiratory Care Education (CRCE) contact hours for respiratory therapists.

This course is relevant to sleep technologists and sleep center managers seeking to implement out-of-center sleep testing and develop innovative programs to keep your sleep centers on the cutting edge of sleep medicine.

Topics include insurance perspectives, improving treatment adherence, the evolving role of the technologist, the care continuum and use of social media. Upon completion of the course, participants will be able to review technologies for outof-center sleep testing; summarize the insurance perspective on sleep apnea diagnosis and treatment; appraise methods for improving patient retention and long term adherence to treatment; evaluate pre-certification strategies and discriminate among available social media opportunities.

All attendees must pre-register; on-site registration will not be accepted. Space is limited, so register today! Download the course brochure and register online at www.aastweb.org. 

Preliminary Schedule and Topics Introduction and Overview Shalanda Mitchell, RST, RPSGT – Course Chair Evolving Role of RPSGTs Rita Brooks, RST, RPSGT Pre-Diagnosis of Sleep Related Breathing Disorders Dennis Hwang, MD Who’s in the Game? Understanding Pre-certification Policies Brooke Harding Cardiac Signals and Analysis Harry Whitmore, RST, RPSGT Equipment Updates Kimberly Minton, BS, RRT Insurance Coverage Carolyn Winter-Rosenberg Compliance Shari Angel Newman, RPSGT Customer Service/Patient Education Shalanda Mitchell, RST, RPSGT Longitudinal Care Carl Stepnowsky, PhD Pediatrics: How to Grow it and What to Know Joel Porquez, RPSGT Social Media Patrick Murray Policy and Procedure Manual Melinda Trimble, RST, RPSGT

A2 Zzz 22.1 | March 2013

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NEURODIAGNOSTICS AND SLEEP SCIENCE: THE WORLD’S FIRST BACHELOR DEGREE

By Mary Ellen Wells, MS, RPSGT, R.EEG T., R.NCS T.

Program Overview Sleep science and neurodiagnostics are unique professions that are vital in the diagnosis and treatment of sleep disorders, nervous system disorders and behavioral and psychiatric disorders. Technologists use a variety of techniques to study electrical activity of the brain, nervous system, respiratory system and the cardiovascular system. Previously, the highest degree available in polysomnography was an associate degree. A great need has emerged across the U.S. for advanced technologists to fill leadership roles in education, clinical practice, research, industry and government. The Neurodiagnostics and Sleep Science (NDSS) degree was created just for this purpose.

The NDSS Bachelor of Science (B.S.) program is the first degree of its kind anywhere in the world. It is offered through the University of North Carolina at Charlotte with collaborative coursework from the University of North Carolina at Chapel Hill. The curriculum represents coursework in advanced practice, administration, research, education and leadership.1 The uniqueness of the NDSS program lies in the fact that it is not only the first Bachelor’s program with a concentration in sleep medicine and neurodiagnostics, but it is also offered via distance education. The name given to this type of program is “2+2”, which means students admitted to the NDSS program already have an earned associate degree (two years of study) and complete an additional two years of study (12 courses) at the University to earn a bachelor’s degree. Minimum admission criteria include1: • Current registration as a RPSGT or R. EEG T. by the Board of Registration of Polysomnographic Technologists (BRPT) or the American Board of Registration of Electroencephalographic and Evoked Potential Technologists (ABRET) • Have a cumulative grade point average of 2.0 or better from an associate degree program in Polysomnography, Neurodiagnostic Technology, Respiratory Therapy or an Associate in Arts/Science College Transfer from an accredited institution

Another unique feature of the NDSS program is that it is offered via distance education (online) - meeting the needs of busy and working sleep professionals. The one exception is that students do complete a practicum during the first summer of the program, which typically can be completed at a facility local to the student and scheduled around the student’s work schedule.

Program Goals Graduates of the NDSS program will hold influential positions utilizing their professional knowledge and critical thinking skills to address the multi-faceted issues in sleep medicine and healthcare in general. These positions may be available in hospitals, specialized sleep and epilepsy labs, private practice, educational institutions, research facilities, and equipment design, sales, and manufacturing companies. In particular, NDSS graduates will2: • Be prepared to work in electrophysiological fields (laboratories, hospitals, industry, colleges) • Problem solve individually and in teams addressing unique issues arising in the health care arena involving the overlap of electrophysiology, laboratory science, management and education • Be prepared to teach at the community college level in electrophysiological areas

A2 Zzz 22.1 | March 2013

 Continued on Page 12

• A grade of at least a C in all coursework taken by the end of the semester prior to the semester for which application is made

History The NDSS program was developed in North Carolina because of a critical shortage of sleep technologists, which translated to a shortage of qualified educators in the North Carolina community colleges and a shortage of individuals to fulfill leadership roles in sleep medicine, such as lab managers. The North Carolina Community College System responded to the critical shortage of technologists by creating new polysomnography educational programs. The NDSS program was then developed with one of its goals to produce graduates qualified as instructors and directors in these programs. Program planning began in 2008 when the first director of the NDSS program was brought on board. The first cohort enrolled in 2011 and is scheduled to graduate in May of 2013. A new cohort is admitted every spring for fall semester enrollment.

 Continued from Page 11

12 • Create and promote policy that improves cost-effective quality practices • Be well prepared for additional advanced degrees Course Listing & Descriptions NDSS 3101 - Pathophysiology of Sleep, Neurological, and Related Disorders: This course is a study of diseases that affect the sleep/wake cycle, the nervous system and psychiatric and behavioral disorders. Topics include etiology, clinical manifestations, pharmacology, disease prevention, and treatment.

NDSS 3102 - Neurological and Sleep Diagnostic, Therapeutic, and Monitoring Services: This course explores current services of sleep centers and neurophysiology laboratories. Topics include quality assurance, clinical reasoning, evidence based practice, instrument performance verification, polysomnography, electroencephalography, multiple sleep latency test, maintenance of wakefulness test, long term epilepsy monitoring, and cardiopulmonary assessment and monitoring.

NDSS 3104 - Advanced Sleep and Neurodiagnostic Clinical Procedures: This course explores advanced clinical procedures performed in sleep centers and neurophysiology laboratories.

Topics include nerve conduction velocity testing, autonomic testing, nocturnal ventilator support, electronystagmography, troubleshooting, equipment verification and maintenance, evidence based practice, and current issues and trends.

NDSS 3405 - Practicum: Sleep disorders center and clinical neurophysiology laboratory clinical experience.

NDSS 4101 - Principles and Practice of Healthcare Education: This course provides a foundation in the principles and practice of healthcare education. Topics include instructional theories, design, learning outcomes, assessments, and evaluation.

NDSS 4104 - Advanced Physiological Monitoring and Data Acquisition: This course explores the advanced clinical procedures performed in clinical neurophysiology laboratories and operating rooms. Topics include visual, brainstem auditory, and somatosensory evoked potentials, intraoperative neurophysiologic monitoring, and equipment verification, troubleshooting, and maintenance.

NDSS 4105 - Leadership in Healthcare Organizations: This course focuses on the theories and practices of leadership in health care. Global, social, legal, political, economic, and ethical issues are explored.

NDSS 4406 - Internship: Sleep and clinical neurophysiology laboratory educational/management internship with mentoring component.

NDSS 4107 - Sleep and Neurodiagnostic Sciences Capstone: Students complete a project and presentation culminating from

the undergraduate course of study. Project topics are current and relevant within the professional discipline and will provide students the opportunity to summarize, evaluate, and integrate knowledge gained throughout the undergraduate major.

RESP 4102 - Program Administration: Administration, financial, human resource, legal, and policy concepts and issues in outpatient, inpatient, public, and private sector settings.

RESP 4103 - Evidence-Based Practice: This course will provide the student with an introduction to the concept of evidence-based practice and an opportunity to acquire the skills necessary to be able incorporate evidence and best practices into professional work. These include an understanding of research methods and the approach to critical appraisal of research literature.

NURN 4201 - Information Technology: Applications in Health Care: A study of the use of computers and information technology in health care. Emphasis is placed on development of the knowledge and competencies necessary for selective use of and evaluation of informatics, computer technology and data management in health care.

For more information, visit www.med.unc.edu/ahs/ndss or contact Mary Ellen Wells at mwells@med.unc.edu or (919) 843-4673.

REFERENCES: 1.

The University of North Carolina at Charlotte (2013).

Bachelor of science degree in neurodiagnostics and sleep science. Retrieved Jan 14th, 2013: http:// distanceed.uncc.edu/BS-Neurodiagnostics-and-SleepScience.

2.

The University of North Carolina at Chapel Hill (2013). Department of Allied Health Sciences.

Neurodiagnostics and sleep science. Retrieved Jan 14th, 2013: http://www.med.unc.edu/ahs/ndss. 

A2 Zzz 22.1 | March 2013

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CONTINUING EDUCATION CREDIT OFFERING INSTRUCTIONS FOR EARNING CREDIT

AAST members who read A2Zzz and submit the AAST CEC Evaluation Form by the deadline can earn 2.00 AAST Continu­ing Education Credits (CECs) per issue – for up to 8.00 AAST CECs per year. AAST CECs are accepted by the American Board of Sleep Medicine (ABSM) and the Board of Registered Polysomnographic Technologists (BRPT).

To earn AAST CECs, carefully read four of the designated CEC articles from the list below and complete the evaluation form. You must fax or email your completed form to the AAST national office, or have it postmarked, by the deadline of June 1, 2013. After the successful completion of this educational activity, a confirmation letter acknowledging that you have earned 2.00 AAST CECs will be sent six to eight weeks after the deadline to the email address that you have on file with the AAST.

COST

The A2Zzz continuing education credit offering is an exclusive learning opportunity for AAST members only and is a free benefit of membership.

NEW: DOWNLOAD THE AAST CEC EVALUATION FORM FOR A2Zzz

Claiming continuing education credits (CECs) by reading A2Zzz just got easier with the new downloadable AAST CEC Evaluation Form. Simply download the form and complete the evaluation on your computer. Then return your completed form to the AAST as an email attachment to claim your CECs. Or continue to return your completed form by fax or mail – it’s your choice!

STATEMENT OF APPROVAL

This activity has been planned and implemented by the AAST Board of Directors to meet the educational needs of sleep technologists. AAST CECs are accepted by the American Board of Sleep Medicine (ABSM) and the Board of Registered Polysomnographic Technologists (BRPT). Individuals should only claim credit for the articles that they actually read and evaluate for this educational activity.

STATEMENT OF EDUCATIONAL PURPOSE/OVERALL EDUCATIONAL OBJECTIVES

A2Zzz provides current sleep-related information that is relevant to sleep technologists. The magazine also informs readers about recent and upcoming activities of the AAST. CEC articles should benefit readers in their practice of sleep technology or in their management and administration of a sleep disorders center.

Readers of A2Zzz should be able to do the following: • Analyze articles for information that improves their understanding of sleep, sleep disorders, sleep studies and treatment options • Interpret this information to determine how it relates to the practice of sleep technology • Decide how this information can improve the techniques and procedures that are used to evaluate sleep disorders patients and treatments • Apply this knowledge in the practice of sleep technology You must fax or email your completed form to the AAST national office, or have it postmarked, by the deadline of June 1, 2013.

Read and evaluate four of the following articles to earn 2.0 AAST CECs: Page # Sleep-Disordered Breathing and Diabetic Retinopathy................................................................................................. 15-17 Objective: Understand that the presence of OSA in people with diabetes may hasten the progression of retinopathy.

It’s All in The Genes................................................................................................................................................... 18-20 Objective: Identify differential thresholds for symptoms, genetic susceptibility to disease states and vulnerability to sleep deprivation.

Patient and Individual Safety in the Sleep Center: A Physical and Information Technology Perspective........................... 21-24 Objective: Define patient safety issues from both a physical and information technology perspective and effectively implement actions and policies to improve overall patient safety in a sleep center.

Legal Notes: The Impact of Out of Center Sleep Testing............................................................................................... 25-26 Objective: Understand the impact of OCST on sleep techs.

Technical Corner: The Evolving Definition of Hypopnea: Desaturations, Arousals, Both or Either?................................ 27-28 Objective: Understand the evolution of hypopnea scoring over time and the new hypopnea scoring rule.

Why Did My CPAP Beat Me Up........................................................................................................................................29-31 Objective: Understand that bruising associated with CPAP should prompt a search for a bleeding diathesis.

A2 Zzz 22.1 | March 2013

14

AAST CEC EVALUATION FORM VOLUME 22 NUMBER 1

To earn 2.00 hours of continuing-education credit (CEC), carefully read four of the designated CEC articles from the list on the previous page. Then evaluate each article using the statements on this form. When completing this form be sure to include in the appropriate blanks the page number for each article that you read.

After you have completed and signed this form you must fax it to the American Association of Sleep Technologists (AAST) national office at 630-737-9788, or have it postmarked, by the deadline of June 1, 2013 in order to receive credit. This service is an exclusive learning opportunity for AAST members only and is a free benefit of membership After the successful completion of this educational activity, a confirmation letter acknowledging that you have earned 2.00 AAST CECs will be sent six to eight weeks after the deadline to the email address that you have on file with the AAST 5=Strongly Agree, 4=Agree, 3=Unsure, 2=Disagree, 1=Strongly Disagree

Article 1 Article 2 Article 3 Article 4 Page# _______ Page# _______ Page# _______ Page# ________ 1. EDUCATIONAL VALUE: I learned something new that was important.

5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 54321 I verified some important information.

5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 54321 I plan to discuss this information with colleagues.

5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 54321 I plan to seek more information on this topic.

5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 54321 My attitude about this topic changed in some way.

5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 54321 This information is likely to impact my practice.

5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 54321 2. READABILITY FEEDBACK: I understood what the authors were trying to say.

I was able to interpret the tables/figures (if applicable).

Overall, the presentation of the article enhanced my ability to read and understand it.

5 4 3 2 1 5 4 3 2 1

5 4 3 2 1 5 4 3 2 1

5 4 3 2 1 5 4 3 2 1

54321 54321

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

54321

PLEASE PRINT LEGIBLY OR TYPE 3. ADDITIONAL COMMENTS/FEEDBACK TO BE USED BY THE AAST CEC COMMITTEE:

4. COMMITMENT TO CHANGE: What change(s), if any, do you plan to make in your practice as a result of reading any of these 4 articles?

5. STATEMENT OF COMPLETION: I attest to having completed the AAST CEC activity (sign below).

Signature Date

AAST Membership Number#

Phone: ________/________/________Fax: ________/________/ ________ E-mail: Name (please print legibly) RPSGT



RST



Address City State

Zip

You must fax your completed form to the AAST national office, or have it postmarked, by June 1, 2013 AAST National Office, 2510 North Frontage Road, Darien, IL 60561, Fax: (630) 737-9788

A2 Zzz 22.1 | March 2013

15

SLEEP-DISORDERED BREATHING AND DIABETIC RETINOPATHY

By Regina Patrick, RPSGT

R

etinopathy is disease of or damage to the retina. Injury to the retinal blood vessels, decreased retinal blood flow or abnormal growth of retinal blood vessels are features of retinopathy that can cause vision loss. Sleep-related disordered breathing may contribute to the development of retinopathy.

Some researchers have reported vascular changes in the retinas of people with obstructive sleep apnea (OSA).1-5 The association between retinopathy and OSA may be especially problematic for people with diabetes since diabetes itself is a risk factor for retinopathy. Approximately 80% of people who have had type 2 diabetes for 20 to 25 years develop retinopathy.6 Diabetes is the leading cause of new cases of blindness among adults 20 to 74 years old.7 Some research now indicates that presence of OSA in people with diabetes may hasten the progression of retinopathy.

Diabetes is an endocrine disorder in which the hormone insulin is produced in insufficient amounts or the body’s cells do not respond to (i.e., resist) the effects of insulin. Insulin plays a role in removing excessive levels of glucose from the blood. Two forms of diabetes exist: type 1 and type 2. In type 1 diabetes, a person does not produce sufficient amounts of insulin and must depend on an exogenous source of insulin to live. Type 1 diabetes is often called “insulin-dependent diabetes.” In type 2 diabetes, a person is resistant to the effects of insulin (although insulin levels may be normal) or insulin levels are reduced; however, the person’s blood glucose level can often be maintained with dietary changes and/or medication. Type 2 diabetes is often called “non–insulin-dependent diabetes.” Both forms of diabetes are associated with pathological changes in the small blood vessels of the eye, kidney, and small arteries throughout the body.

Improper utilization or production of insulin impairs many metabolic functions such as fluid balance and the metabolism of proteins, fats, and carbohydrates. As a result, a person with untreated diabetes may experience excessive thirst, diuresis (i.e., frequent urination), polyuria (i.e., excretion of a large amount of urine), dehydration, excessive hunger with weight loss, or ketoacidosis (i.e., the accumulation of ketone bodies, which are acidic molecules formed as a byproduct of faulty glucose metabolism).

REGINA PATRICK, RST, RPSGT

Japanese researcher Tomoaki Shiba8 and colleagues recently found that sleep-related disordered breathing (SDB) may be a risk factor for neovascularization in people with diabetes. In the study, Shiba compared the prevalence of SDB in diabetic patients who had neovascularization with its prevalence in diabetic patients who did not have neovascularization. All patients were monitored by pulse oximetry to determine the number of desaturations per hour of sleep (i.e., the oxygen desaturation index [ODI]). If the patient’s ODI was greater than 5 desaturations per hour, the patient was diagnosed as having SDB. Shiba noted SDB in 62 percent of the patients with neovascularization, compared to 46 percent of the patients without neovascularization. There were a significantly greater number of desaturations in the neovascularization group (12.6 desaturations) in comparison to the non-neovascularization group (6.6 desaturations). Statistical analysis indicated that ODI was one risk factor for neovascularization in diabetic patients.

Other researchers have similarly noted that sleep-related disordered breathing – in particular OSA – appears to play a role in the development of retinopathy in people with diabetes.

For example, Semaan Kosseifi5 and colleagues investigated the correlations between various features of OSA (e.g., oxygen desaturation) and diabetes (e.g., retinopathy) in veterans

A2 Zzz 22.1 | March 2013

 Continued on Page 16

Regina Patrick, RST, RPSGT, has been in sleep field for more than 20 years and works as a sleep technologist at the Wolverine Sleep Disorders Center in Tecumseh, Mich.

Diabetic retinopathy can be nonproliferative or proliferative. In nonproliferative diabetic retinopathy, retinal blood vessels leak plasma or fatty substances. This decreases or blocks blood flow within the retina. The retinal blood vessels may also develop microaneurysms (i.e., a balloon-like outpouching of a vessel) that can burst and leak blood within the retina. Some people with nonproliferative retinopathy experience no symptoms, but others may experience symptoms such as central vision loss and decreased night vision. In proliferative diabetic retinopathy, new vessels begin to grow (i.e., neovascularization) into other areas of the eye such as the vitreous humor or the optic disc. (The vitreous humor is a semisolid substance that fills the posterior portion of the eye between the lens and retina; the optic disc is the portion of the eye where the fibers from the retinal cells converge and extend out of the eye to form the optic nerve.)

New blood vessels that grow into the vitreous humor can rupture and cause sudden vision loss. Scar tissue may form in the retina as the tissue attempts to heal the damage caused by ruptured blood vessels. However, scar tissue can pull retinal tissue away from its supportive underlying tissue – a process called retinal detachment – and contribute to vision loss. Scar tissue that forms on the macula – a specialized area on the retina that is responsible for central vision – can cause problems with central vision such as seeing an “inky” spot in the center of one’s vision.

 Continued from Page 15

16 who had well-controlled type 2 diabetes. Kosseifi found a significant positive correlation between retinopathy and the number of apneas or hypopneas per hour of sleep (i.e., the prevalence of retinopathy increased with the number of apneas and hypopneas), and found a significant, inverse relationship between oxygen desaturation and retinopathy (i.e., the lower a person’s oxygen desaturation during the night, the greater the risk of retinopathy). Sophie West9 and colleagues assessed retinopathy and maculopathy (i.e., injury or damage to the macula) in type 2 diabetic men with and without OSA. West found that retinopathy and maculopathy were significantly worse in diabetic men with OSA; that OSA was a significant independent predictor of retinopathy; and that OSA was the only independent significant predictor of maculopathy. Yaprak Unver10 and colleagues found that diabetic patients with OSA typically had three or more infarcts (i.e., areas of dead tissue resulting from low blood flow) in the retina of each eye, whereas diabetic patients without OSA rarely had infarcts in the retina.

Based on this finding, Unver suggests that OSA may contribute to a more aggressive course of retinopathy in a person with diabetes.

OSA may contribute to retinopathy through the hemodynamic and physiological changes that occur during an episode. In OSA, upper airway tissues such as the tonsils, tongue, and adenoids block (i.e., obstruct) the airway during sleep. The upper airway muscles, which would normally keep the airway open during sleep, relax excessively during sleep in people with OSA and allow the upper airway tissues to collapse into and obstruct the airway. During the obstruction, a person continues to make respiratory movements but little or no air enters the lungs. The lack of airflow (i.e., lack of breathing) is apnea. The blood oxygen consequently falls. When the blood oxygen falls to a certain point, the person arouses briefly to take some deep breaths to restore the blood oxygen level. Once it is restored, the person falls promptly back to sleep. However, sleep allows the upper airway muscles to relax again, setting the stage for another episode of OSA. Hemodynamic changes during an OSA episode involve sudden decreases and increases in blood flow and blood pressure. During the apnea phase, blood flow and blood pressure decreases; during the arousal phase, blood flow and blood pressure suddenly increases. The frequent changes in blood flow and blood pressure during an OSA episode may damage fragile small blood vessels in the retina or cause them to break and leak blood.

Hypoxemia (i.e., low blood oxygen level) and hypercapnia (i.e., high blood carbon dioxide level) are physiological effects of OSA that can affect the function of blood vessels. During the apnea phase of an OSA episode, hypoxemia and hypercapnia occur. Hypoxemia induces vasodilation (i.e., opening) of the central retinal artery. Vasodilation of this artery can compress the central retinal vein since the two vessels travel closely side by side through the center of the optic nerve. Compression

of the retinal vein can decrease the outflow of blood from the retina and damage the retina. Hypercapnia appears to induce neovascularization and vascular degeneration; however, scientists currently can not explain how hypercapnia induces neovascularization.11 Treating OSA reduces the risk of cardiovascular disease (e.g., stroke, heart attack) and may improve glucose control in some diabetics. With this in mind, scientists have begun investigating the impact of OSA treatment on retinopathy. In a recent study, Rebecca Mason12 and colleagues recorded the visual acuity of 28 diabetic patients with macular edema (i.e., swelling of the macula due to the retention of fluid) and OSA. All patients were treated by continuous positive airway pressure (CPAP), which involves blowing a continual flow of pressurized air into the airway through a nasal or or nasal mask to prevent upper airway collapse. The patients were grouped as high treatment compliance (i.e., the CPAP mask was used 2.5 hours or more night) or low treatment compliance (i.e., the CPAP mask was used less than 2.5 hours per night). At the end of 6 months, the high treatment compliance group had improved visual acuity.

However, there was no significant improvement in macular edema. Because not many studies exist focusing on the effect of OSA treatment on retinopathy, future studies may more clearly show whether OSA treatment improves retinopathy.

Although many studies indicate a relationship between OSA and retinopathy, whether mild SDB contributes to retinopathy is unclear. To investigate this, researchers Lori Boland13 and colleagues calculated the average number of apneas and hypopneas per hour of sleep in a group of middle-aged and elderly subjects who were assessed for retinopathy. Boland noted that the prevalence of retinopathy was slightly higher in people with a high number of apneas and hypopneas. However, after adjusting for age, body-mass index, hypertension, diabetes, and other factors, statistical analyses indicated that retinopathy was not associated with SDB. Boland therefore concluded there is no relation between SDB and retinopathy, but encourages more research to determine if the findings of other researchers will be consistent or inconsistent with her findings.

Because of the apparent relation between OSA and diabetes, some researchers suggest that physicians should screen diabetic patients for OSA if they have symptoms such as snoring, fragmented sleep, daytime somnolence, and hypertension,5,10 or if they have an accelerated course of retinopathy.10 Future studies may more clearly reveal the extent that treating OSA or other sleep-related disordered breathing can slow or reverse the progression of retinopathy. If future studies prove that treating OSA or SDB can improve retinopathy, then identifying and treating OSA or SDB early may spare a diabetic person’s vision or delay the progression of retinopathy.

A2 Zzz 22.1 | March 2013

17 REFERENCES: 1.

Chou KT, Huang CC, Tsai DC, et al. Sleep apnea and risk of retinal vein occlusion: A nationwide population-based study of Taiwanese. American Journal of Ophthalmology. Jul 2012;154(1):200-205 e201.

2.

Glacet-Bernard A, Leroux les Jardins G, Lasry S, et al. Obstructive sleep apnea among patients with retinal vein occlusion. Archives of Ophthalmology. Dec 2010;128(12):1533-1538.

3.

Kanai H, Shiba T, Hori Y, et al. Prevalence of sleep-disordered breathing in patients with retinal vein occlusion. Nihon Ganka Gakkai Zasshi. Feb 2012;116(2):81-85 [article in Japanese].

4.

Mojon DS, Hedges TR 3rd, Ehrenberg B, et al.

Association between sleep apnea syndrome and nonarteritic anterior ischemic optic neuropathy.

Archivies of Ophthalmology. May 2002;120(5):601-605.

5.

Kosseifi S, Bailey B, Price R, et al. The association between obstructive sleep apnea syndrome and microvascular complications in well-controlled diabetic patients. Military Medicine. Nov 2010;175(11):913-916.

6.

Professional Guide to Diseases. 5th ed. Springhouse, PA: Springhouse Corporation 1995.

7.

National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics, 2011.

Feb 2011; NIH Publication No. 11-3892. Available at.

Accessed 1-1-2013, 2013.

8.

11. Leduc M, Kermorvant-Duchemin E, Checchin D, et al. Hypercapnia- and trans-arachidonic acid-induced retinal microvascular degeneration: Implications in the genesis of retinopathy of prematurity. Seminars in Perinatology. Jun 2006;30(3):129-138.

12. Mason RH, Kiire CA, Groves DC, et al. Visual improvement following continuous positive airway pressure therapy in diabetic subjects with clinically significant macular oedema and obstructive sleep apnoea: Proof of principle study. Respiration.

2012;84(4):275-282.

13. Boland LL, Shahar E, Wong TY, et al. Sleep-disordered breathing is not associated with the presence of retinal microvascular abnormalities: The Sleep Heart Health Study. Sleep. May 1 2004;27(3):467-473. 

2013 CATALOGS

COMING SOON

Shiba T, Takahashi M, Hori Y, et al. Relationship between sleep-disordered breathing and iris and/ or angle neovascularization in proliferative diabetic retinopathy cases. American Journal of Ophthalmology.

Apr 2011;151(4):604-609.

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18

IT'S ALL IN THE GENES

By Joanne Hebding, RPSGT

The age-old questions centered on environment versus heredity, nature versus nurture or free will versus preprogramming have been the source of many heated discussions over the years.

Questions asking what dictates what we do, how we feel or how we respond to situations have baffled the greatest scientific minds. Why do some people respond better than others to environmental or physical stressors?

Many pulmonologists have pondered why one asthma patient having dyspnea and a forced expiratory volume in 1 second (FEV1) of 90% is very short of breath, while a second asthma patient with a FEV1 of 50% is hardly short of breath at all.

Some explanation may be that there are different thresholds for the same respiratory symptoms from one patient to another.

The answer might be multifactorial, based on genetic wiring of dyspnea receptors, the degree of airflow obstruction and the degree of overdistension, the amount of mucus and the extent of disturbed elastic recoil. Another anomaly is seen in patients who get very little emphysema or lung cancer when smoking two packs of cigarettes per day versus another set of patients who develop severe disease. A differential genetic susceptibility may dictate the disease state and allow people to be more susceptible to the effects of environmental stressors.

How does this related to a patient’s sleepiness? We have all seen patients with mild obstructive sleep apnea (OSA) with a relatively mild apnea-hypopnea index (AHI) of 8/hr who are extremely sleepy, and others with severe OSA with a corresponding AHI of over 60 who are only mildly sleepy. How can this be explained?

A patient’s vulnerability towards sleepiness might be multifaceted; based on genetic predisposition, integrity of the wake centers in the brain, the integrity of neurotransmitter levels and environmental stressors. Common environmental stressors that can lead to sleepiness are sleep deprivation, sedating medications, medical illnesses or lack of physical activity.

Testing for genetic predisposition of the LHA DQB0106 gene for narcolepsy has emerged based on literature published by

Asaka, Juji and Honda in 1983.¹ A patient’s genetic structure might allow the patient to be more susceptible to environmental stressors such as infections. Researchers are looking into the possibility that narcolepsy may be caused by some type of autoimmune disorder. They are suggesting that the immune system may accidentally turn off the specific area of the brain that controls alertness and sleep, possibly injuring or destroying it. Further studies that characterize the T cells involving cataplexy-narcolepsy would help to reveal whether environmental factors, such as infections, contribute to the disorder.³ So what tools do sleep specialists use to assess sleepiness? The Epworth Sleepiness Scale (ESS) is commonly used to assess sleepiness on a scale ranging from 0-24. A score of greater than 10 usually will signal the sleep specialist that this is a sleepy patient. The Stanford Sleepiness Scale (SSS) can also be used to assess sleepiness. The Fatigue Severity Scale (FSS) using a scale ranging from 9 to 63 is another tool used to assess fatigue levels.

A score of >36 indicates a high fatigue level.

Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you.

Use the following scale to choose the most appropriate number for each situation below: 0 = would never doze

2 = moderate chance of dozing 3 = high chance of dozing Make sure you circle a number for each situation.

SITUATION

1. Sitting and Reading

2. Watching Television

3. Sitting inactive in a public place (e.g., a theater or meeting) 4. As a passenger in a car for an hour without a break

JOANNE HEBDING, RPSGT Joanne Hebding, RPSGT, has been in the sleep field since 1988 and is manager of the Tallahassee Memorial Sleep Center in Florida.

1 = slight chance of dozing

5. Lying down to rest in the afternoon when circumstances permit 6. Sitting and talking to someone

7. Sitting quietly after lunch without alcohol

A2 Zzz 22.1 | March 2013

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TOTAL SCORE: __________ (Maximum = 24. Normal < 10) Fatigue Severity Scale This questionnaire contains nine statements that rate the severity of your fatigue symptoms. Read each statement and circle a number from 1 to 7, based on how accurately it reflects your condition during the past week and the extent to which you agree or disagree that the statement applies to you. A low number indicates strong disagreement with the statement, whereas a high value indicates a strong agreement with the statement.

4. Fatigue interferes with my physical functioning 5. Fatigue causes frequent problems for me

6. My fatigue prevents sustained physical functioning 7. Fatigue interferes with carrying out certain responsibilities

8. Fatigue is among my three most disabling symptoms 9. Fatigue interferes with my work, family, or social life

3. I am easily fatigued

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2. Exercise brings on my fatigue

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Make sure you circle a number for every statement.

1. My motivation is lower when I am fatigued

1 2 3 4 5 6 7

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The first choice of procedures to assess patient sleepiness is usually a polysomnogram (PSG). If the PSG is normal, a Multiple Sleep Latency Test (MSLT) might be ordered. The MSLT can help determine the level of sleepiness or assist in the diagnosis of narcolepsy or idiopathic hypersomnia. The standard MSLT protocol per American Academy of Sleep Medicine (AASM) practice parameters consists of five nap opportunities

ď&#x192;&#x160; Continued on Page 20

FIGURE 1: PSG

A2 Zzz 22.1 | March 2013

 Continued from Page 19

20

FIGURE 2: MSLT WITH 5 SOREMP

performed at two hour intervals. The initial nap opportunity begins 1.5 to 3 hours after termination of the nocturnal PSG recording. The protocol indicates that “a shorter four-nap test may be performed, but this test is not reliable for the diagnosis of narcolepsy unless at least two sleep onset rapid eye movement (REM) periods have occurred.” ² The MSLT indicates pathologic sleepiness if the mean sleep onset is <5 minutes, and assists in the diagnosis of narcolepsy if 2 or more sleep onset REM periods are recorded during the MSLT. Normal mean sleep onset is usually >10 minutes.

Case Review Patient presents with a four-year history of excessive daytime sleepiness, daytime fatigue, non-refreshing sleep, and frequent awakenings. He denies cataplexy or sleep paralysis, but does report hypnagogic dreaming. He has fallen asleep while driving twice in his lifetime. He sleeps about 7 hours each night and takes a 2 hour nap almost every afternoon.

Past medical history is unremarkable. The patient takes no medications. Epworth sleepiness scale score is elevated at 13.

The PSG report revealed an AHI of 7.9 and the MSLT was completed following the PSG. The patient was recommended to begin continuous positive airway pressure (CPAP) therapy first, then if continuing to be excessive sleepy, to begin a trial of Provigil.

With each patient presentation, sleep personnel will note differential thresholds, differential susceptibility and differential vulnerability among patients. The answers are not easily detected, and each patient must be treated individually.

In conclusion, I want to leave you with this thought: “Genetics is the loaded gun; Environment is the trigger that pulls the gun”.

Special Thanks to Dr. David Y. Huang, Medical Director of the Tallahassee Memorial Sleep Center for use of his information presented in case conference in December 2012.

REFERENCES: 1.

Honda Y, Asake A, Tanaka Y, Juji T. Discrimination of narcolepsy by using genetic markers and HLA. Sleep Res.,1 2: 254, 1983.

2.

M. Littner, et al. AASM practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test. Sleep, 28 (1), 2005.

3.

Hallmayer J et al. Narcolepsy is strongly associated with the tcr alpha locus. Nature Genetics; published online May 3, 2009. 

A2 Zzz 22.1 | March 2013

21

PATIENT AND INDIVIDUAL SAFETY IN THE SLEEP CENTER: A PHYSICAL AND INFORMATION TECHNOLOGY PERSPECTIVE

By Mark D. Eley, MS, RST, RPSGT, RRT-NPS, RPFT.

Introduction Patient and individual safety is a primary and significant concern and objective of any healthcare encounter including sleep center activities. Patient safety in a sleep center can manifest in many forms including physical safety and security of patients and staff members. Health information technology (HIT) activities also play an important role in the overall profile of patient safety and are inclusive of multiple and various activities. This article evaluates patient safety in a sleep center in two significant domains: Physical safety of all individuals involved in sleep center activities and overall safety from an HIT perspective.

The World Health Organization (WHO) states the following1:

Physical Safety in a Sleep Center Sleep center patients can present with a variety of physical needs.

This can translate into safety concerns that all sleep technologists must be aware of. Additionally a sleep center may be exposed to broad safety concerns from a variety of disparate sources. These physical safety concerns can include the following:

• Prevention strategies should emphasize education, training, creating safer environments, prioritizing fall-related research and establishing effective policies to reduce risk.

• Fall risks • Physical transportation issues including the possible adverse effect of sleeping aids • Inappropriate patient, family member, or staff conduct including security concerns • Natural disasters

• Falls are the second leading cause of accidental or unintentional injury deaths worldwide.

• Each year an estimated 424,000 individuals die from falls globally of which over 80% are in low- and middle-income countries.

• Adults older than 65 suffer the greatest number of fatal falls.

• 37.3 million falls that are severe enough to require medical attention occur each year.

Preventative and reparative measures averting falls in a sleep center can include the following: • Identifying patients who may be at risk for a fall especially based on the above information • Structuring a sleep center environment such that fall risks are minimized – this can include removing fall obstacles in a patient room and being observant of the patient care environment • Establishing protocols to follow after a fall that may occur including family and staff personnel to notify

• Protection from infectious disease processes Fall Risks A fall risk can be a significant concern in a sleep center given that sleep center patient care activities generally occur during nocturnal hours when patients may have a greater likelihood of disorientation, especially when in unfamiliar surroundings and in possibly dim-lit surroundings. Sleep technologists should be attentive to all patients, especially those who are elderly, physically compromised or who have other limitations. These individuals may be identified as requiring special assistance when engaging in a sleep study.

Mark D. Eley, MS, RST, RPSGT, RRT-NPS, RPFT, has been in the sleep field for more than 20 years and is a polysomnographic technologist at Community Hospital Anderson in Anderson, Ind. He earned a master’s degree in health informatics from the University of Illinois at Chicago.

Additional facility-specific policies and procedures can be developed based on the degree of fall risk potential.

Transportation Issues It is not uncommon for sleep center patients to be given a prescribed or over-the-counter (OTC) sleeping aid. There are several categories of available sleeping aids including benzodiazepines, non-benzodiazepines, melatonin receptor agonists and antidepressants.2 These medications can include the following: • Ambien® • Lunesta® • Restoril® • Sonata® • NyQuil® • Tylenol PM®

A2 Zzz 22.1 | March 2013

 Continued on Page 22

MARK D. ELEY, MS, RST, RPSGT, RRT-NPS, RPFT

• Debriefing key personnel after a fall incident to identify mechanisms to prevent additional incidents

 Continued from Page 21

22 All of these medications are safe, effective and useful when used as prescribed by a physician or other licensed medical provider or as recommended by the manufacturer. However, there are inherent transportation risks associated with any sleeping aid if any individual uses a motor vehicle while still under the influence of the sleeping aid.

If a sleep center patient takes a prescribed or OTC sleeping aid, it is incumbent upon the sleep technologist, as well as the sleep center facility to ensure that the patient either is capable of providing his or her own transportation when leaving the sleep center or has alternative transportation arrangements. This ensures the safety of the patient, associated family members, as well as other individuals who may be in a similar transportation pathway. Verifying that a patient has an adequate transportation mechanism when leaving the sleep center also helps reduce potential liability for the sleep center in case of an adverse event.

Inappropriate Individual Conduct Including Security Concerns Occasionally, and usually rarely, individuals in a sleep center may engage in inappropriate conduct. These activities may include the following: • Acts of aggression directed from one individual to another • Inappropriate violations of patient confidentiality from other individuals in a sleep center environment • Substance abuse violations in the sleep center environment • Other acts of inappropriate conduct that may be viewed as safety risks by any individual Each of these situations may be committed by employees, patients or a patient’s friends or family members. Fortunately these occurrences are usually rare. However, all sleep technologists must be vigilant in their observations of individuals’ behaviors in a sleep center to ensure the safety of all individuals in the sleep center.

Sleep studies most often occur during nocturnal hours when staffing levels may be reduced and opportunities for inappropriate activities may be perceived to be enhanced. These reasons as well are cause for sleep technologists to be aware of any inappropriate individual conduct in the sleep center, regardless of the source, and to be well versed in appropriate preventative and reactionary measures. Ongoing assessment of individuals in a sleep center should occur during the sleep study process and if inappropriate actions occur, the proper individuals must be notified.

Most medical and sleep center facilities have specific policies about responses to inappropriate, aggressive or threatening behavior from any individual. These policies should be followed if an adverse event occurs. These policies can vary depending on the specifics of the facility, as well as the nature of the event.

On-line training modules or safety fairs are often provided for employees in hospitals, sleep centers or other medical facilities.

It’s important for sleep technologists to take advantage of these educational opportunities as they provide ongoing training.

Documentation is an important component of any adverse patient safety incident. To the extent possible, all facts such as date, time and location of an adverse event must be documented.

This information must be subsequently communicated to appropriate personnel when necessary including department managers, facility security individuals, law enforcement personnel and so forth.

Information disclosure about potentially dangerous patients and individuals is generally protected under Health Insurance Portability and Accountability Act (HIPAA) guidelines.

According to an article recently published in Advance for Respiratory Care and Sleep Medicine, “The HIPAA regulations allow a healthcare provider to disclose information about a patient without authorization from the patient and without providing the patient an opportunity to agree or object to the disclosure when the disclosure is made to prevent or lessen the risk of harm. The healthcare provider making the disclosure must have a good faith belief that the disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public. The disclosure must be made to a person that is reasonably able to prevent or lessen the threat.”3 Natural Disasters Natural disasters can occur at any time but fortunately are usually rare in a sleep center. Adverse weather events, power outages and other similar circumstances are some of the more common situations that may be expected to occur. Monitoring patient safety during any event of this type is the primary objective of the sleep technologist. When necessary and when indicated or not contraindicated, moving patients to a more safe or secure location may be necessary. A facility’s policy and procedure for natural disaster events must always be followed if an event of this type occurs.

Infectious Diseases Protection from infection or any contagious disease process is a necessary component of patient safety in a healthcare environment including sleep centers. Especially during the cold and flu season, sleep technologists must observe facilitymandated policies about receiving flu shots and adhering to other infectious disease prevention policies. Hospitals and healthcare facilities often institute visitation restriction policies during the cold and flu season.

An example of a typical visitation restriction policy includes the following guidelines as recommended by the Indianapolis Coalition for Patient Safety4:

A2 Zzz 22.1 | March 2013

23 • No visitors with influenza illness, fever, or cough • No visitors under age 18 (unless special arrangements are made) • No visitors allowed beyond immediate family, partner or significant other Other suggestions for disease prevention during a healthcare or sleep center encounter include the following: • Observe proper hand washing techniques at all times • Stay home when sick • Clean all patient care surfaces with an antiseptic wipe or comparable agent • Be observant of patients who may have infectious diseases and treat them accordingly Sleep centers typically serve more of an outpatient population that doesn’t have visitors. However, these guidelines can apply to both inpatient and outpatient encounters and should be observed in all sleep center situations for best patient safety practices.

Information Technology Aspects of Patient Safety While physical safety is a primary and immediate concern of sleep center activities, information technology (IT) is playing an increasingly crucial role in patient safety in healthcare and in sleep centers.

Specifically, appropriately designed IT activities are indicated for some of the following sleep center activities: • Proper patient identification • Effective dissemination of patient information including appropriate use of electronic health records (EHRs) • Medical device safety for both in lab and out of center sleep testing (OCST) devices

Bar code technology is rapidly being adopted in healthcare for patient identification, as well as other medical activities. Once proper patient identification has been established, many facilities

The concept of a unique patient identifier (UPI) does have drawbacks. According to an article recently published in Healthcare IT News, using identifiers such as first name, last name and birth date can potentially result in both “false positives” and “false negatives”.6 A false positive can result in two different patient records being merged and a false negative can result in the same patient having two separate medical records. Either scenario can have varying and often negative results. Sleep centers typically have a relatively low patient census in comparison to a traditional inpatient hospital facility where it may be more difficult and time consuming to establish accurate patient identification. However, in all patient encounters, effective patient identification is crucial to ensure that appropriate and safe care is provided.

Electronic Health Records and Patient Safety An electronic health record (EHR) is defined as “a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.”7 In the context of patient safety in a sleep center an EHR can be used to provide necessary information about previous relevant medical testing, current medications that may affect a sleep study, patient acuities that may affect safety and other special needs with which a patient may present. Sleep technologists should familiarize themselves with their facility’s EHR and use it to the extent possible prior to a sleep center encounter to best prepare for a safe and secure patient environment.

The Healthcare and Information Management Systems Society (HIMSS) publishes numerous case studies about the use of EHRs and other HIT initiatives in the furtherance of patient safety.8 While most of these scenarios are not directly applicable to the sleep technology profession, the application of EHRs and HIT to the healthcare environment has clearly provided a significant positive impact on overall patient safety.

Medical Device Safety Any electrical device, including a medical device, has the potential to cause harm. Proper use of medical devices is

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 Continued on Page 24

Patient Identification Proper patient identification is a first priority during any healthcare encounter. Accurate patient identification is often performed through a verbal double-identification process that can include having a patient state a full name and birthdate or verify other unique identifiers. Sensitive information such as social security number or dynamic information such as room number or encounter number must not be used. The first scenario may lead to a compromise of identity information that may be used inappropriately and the second scenario may lead to a misidentification of a patient.

will place a wristband or similar product on a patient to act as a unique patient IT identifier device. According to a published white paper from Zebra Technologies, a vendor of many patient identification products, “Bar coding helps healthcare facilities identify, track and manage people, processes and assets.

Positive patient identification is the most critical component of improving patient safety; once an ID solution is in place, it is simpler to accurately track and manage other components such as specimens, medications and materials to enhance patient safety and process efficiency in a multitude of applications across the enterprise. Identification begins in admissions.”5

 Continued from Page 23

24 essential for patient safety. With the increasing use of OCST devices, it is important to ensure patient safety in non-sleep center environments in which monitoring and controls may be reduced.

Sleep technologists must be familiar with all equipment in use in the sleep center environment and must adhere to a facility’s policies about biomedical device safety procedures. Patients should be fully instructed about the use and functionality of equipment required for any out of center activities such as actigraphy or OCST. Additionally, user facilities (hospitals, nursing homes) and health professionals are required to report deaths and adverse events associated with medical devices to the U.S. Food and Drug Administration (FDA) and the device manufacturer.9 Sleep technologists must be aware of this Federal reporting requirement, as well as any facility-specific requirements for device safety and reporting.

capabilities.pdf 6.

Rekindling the patient ID debate. January 29, 2013.

Retrieved February 2, 2013, from http://www. healthcareitnews.com/news/rekindling-patient-iddebate?topic=18.

7.

Electronic health record. HIMSS. 2013.Retrieved January 15, 2013, from http://www.himss.org/ASP/ topics_ehr.asp.

8.

Stories of success. Healthcare and Information Management Systems Society. 2013. Retrieved February 12, 2013, from http://www.himss.org/ storiesofsuccess/caseStudies.asp.

9.

U.S. Food and Drug Administration. Medical devices.

2012. Retrieved December 16, 2012, from http://www. fda.gov/MedicalDevices/Safety/ReportaProblem/ default.htm. 

Conclusion Patient safety is the responsibility of all caregivers in a healthcare environment and during a healthcare encounter. The concept and application of safety is broad and diverse and encompasses many factors including physical safety, elements of information technology and medical device safety. Sleep technologists must be educated and remain informed about all aspects of these issues in order to provide the best care to sleep center patients, and to stay current with the state of the art of the sleep technology profession.

References 1.

Falls. World Health Organization. Fact sheet N°344.

October 2012. Retrieved November 23, 2012, from http://www.who.int/mediacentre/factsheets/fs344/en/ index.html.

2.

Sleeping pills, natural sleep aids & medications: What’s best for you? November 2012. Retrieved November 30, 2012, from http://www.helpguide.org/life/sleep_aids_ medication_insomnia_treatment.htm.

3.

4.

5.

Disclosing information about dangerous patients.

Advance for Respiratory Care and Sleep Medicine.

Smith, M.L., JD, RRT. February 4, 2013. Retrieved February 11, 2013, from http://respiratory-care-sleepmedicine.advanceweb.com/Columns/Legally-Speaking/ Disclosing-Information-About-Dangerous-Patients. aspx.

Indianapolis coalition for patient safety. 2013. Retrieved January 21, 2013, from http://www.indypatientsafety. org/default.aspx.

American Associatio n of Sleep T echnologists

AAST

AAST

AAST

Healthcare Zebra Printing Solutions. 2013. Retrieved January 31, 2013, from http://www.zebra.com/content/ dam/zebra/vertical-information/en-us/healthcare-

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25

LEGAL NOTES: THE IMPACT OF OUT OF CENTER SLEEP TESTING

By Jayme R. Matchinski, Esq.

O

ut of Center Sleep Testing (OCST) has impacted the provision of sleep medicine and how sleep studies are performed. Portable monitoring and home sleep testing (HST) have been terms that are used to describe and define the provision of OCST. During the past several years, OCST has emerged and grown in popularity in primary and specialty care with referrals from non-sleep specialists using OCST at an increasing rate based upon the utilization of technology, reduction of first night effect, cost, and patient convenience.

In some parts of the country, OCST screening is preferred to diagnosis and in-lab sleep testing. The growth of OCST has caused sleep labs, sleep technologists, and sleep physicians to re-evaluate and redesign the provision of sleep medicine, and how patients are screened, evaluated, diagnosed, and treated for sleep disorders. Given the regulatory landscape and decreasing reimbursement trends for sleep studies, many sleep professionals and industry experts predicted the demise of sleep medicine with the growth of OCST. While OCST has changed the landscape of sleep medicine, many sleep professionals have recognized the opportunity to incorporate OCST into their sleep programs to enhance the practice of sleep medicine for the benefit of their patients.

Defining OCST New technology, the convenience and availability of portable monitoring to patients and sleep professionals, the increasing number of primary care physicians and other entrepreneurs who are utilizing OCST to gain access to patients who require sleep studies, commercial insurance medical coverage policies, and regulatory requirements are all contributing factors that define how OCST is being provided across the country.

Patients can purchase a portable monitoring device from the internet and the provision of OCST is less expensive than the traditional in-lab Type I and Type II sleep studies. OCST providers have expounded upon the convenience of OCST for patients who are elderly, morbidly obese, chronically or terminally ill, or are home bound. OCST providers also advocate that OCST reduces the first night effect for patients and therefore the results of an OCST are accurate and provide an effective tool for the screening and diagnosis of Obstructive JAYME R. MATCHINSKI, ESQ.

There is broad spectrum of commercial insurance medical coverage policies. At one end of this insurance coverage spectrum there are commercial insurance companies that do not reimburse for OCST and on the other end there are insurance companies that mandate the provision of OCST prior to their insured patient receiving an in-lab sleep study.

Some insurance companies view OCST as investigational while other insurance companies will only cover an OCST if the physician who interpret and bills for the OCST has the same qualifications required by the Center for Medicare & Medicaid Services (CMS) for the profession component of the interpretation of home sleep tests. The changing regulatory climate and government enforcement efforts combined with the National Coverage Determination (NCD) and Local Coverage Determinations (LCDs) for portable monitoring and home sleep testing have impacted how sleep studies are provided and reimbursed.

Most providers of OCST have billed the studies under CPT Code 98506 or the applicable HCPCS G-Codes: G0398, G0399, or G0400. Pursuant to the 2010 HCPCS definitions, a home sleep test is identified as: G0398– Home sleep study test (HST) with Type II portable monitor, unattended; minimum of seven (7) channels: EEG, EOG, EMB, ECG/heart rate, airflow, respiratory effort and oxygen saturation.

HST has been defined to be a diagnostic procedure that a patient can take in their own home. While the patient sleeps, the HST device monitors the patient’s breathing and records pauses in the patient’s breathing noted as apneas. HST is used to diagnose OSA and is intended for use only by patients who exhibit clinical signs and symptoms of OSA. The American Medical Association (AMA), as the publisher of CPI codes, revised the description of CPT Code 95806, and effective on January 1, 2010, the AMA revision rearranged the criteria and deleted the reference to “ECG” and added the terms “respiratory airflow” in place of “ventilation” and expanded the description of “respiratory effort” by reference to thoracoabdominal movement.

The revised CPT 95806 provides: “985806 Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow, and respiratory effort (e.g., thoracoabdominal movement)”. The AMA’s revision of CPT

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 Continued on Page 26

Jayme R. Matchinski, Esq., a partner with the law firm Hinshaw & Culbertson LLP in Chicago, concentrates on health care law and has counseled sleep disorder centers, physicians and health-care providers nationally. She can be reached at (312) 704-3574 and jmatchinski@hinshawlaw.com.

Sleep Apnea (OSA). There has also been a tremendous increase in the number of primary care physicians and other entrepreneurs who have historically not been involved in the provision of sleep medicine. Many entrepreneurs view OCST as an opportunity to enter the arena of sleep testing for the first time, develop a market for OCST, and capture a revenue source.

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26 Code 95806 adds specific references to respiratory airflow and chest and abdominal movement as separate measures of sleep respiration. Stay tuned regarding coding and reimbursement for OCST as this continues to change and evolve for all payer sources including government programs and other third party payers.

Accreditation of OCST Pursuant to certain LCDs, CMS contractors in different parts of the country are requiring accreditation of home sleep test providers by the American Academy of Sleep Medicine (AASM) or The Joint Commission in order for OCST to be covered as medically necessary. Some Medicare Part B Contractors require accreditation of all non-hospital providers of Medicare sleep tests as a condition of payment or accreditation of the sleep program as a condition precedent to Medicare reimbursement. It is important that all sleep professional and OCST providers check the applicable federal and state regulations and LCDs to ensure compliance and adherence to coverage guidelines and policies.

The AASM has published suggested guidelines for the use of home sleep studies in the diagnosis of OSA. The AASM recommends that HST be used only in the context of a comprehensive sleep evaluation and for the following patients: patients with a high pre-test probability of moderate to severe

OSA; patients with no significant co-morbid condition; patients suspected of having no co-morbid sleep disorder other than OSA; patients unable to be studied in a sleep laboratory; to monitor response to non-PAP treatment after the diagnosis has already been made; and HST should not be used for general screening of asymptomatic patients. Last year, the AASM developed Standards for Accreditation of OCST in Adult Patients.

The Future of OCST and Sleep Medicine OCST is becoming the focus of diagnosis and treatment for most OSA patients. As sleep labs continue to serve more medically complex patients, there will be more specialized roles for sleep technologists. With advances in technology and the provision of sleep medicine to a various patient populations, it appears that outcome-oriented studies are replacing the “comparison of device” studies. Changing regulations and medical policies for coverage by payers, demands greater efficiency with decreasing reimbursement. Sleep technologists and sleep labs should continue to monitor regulator compliance, changing reimbursement rates, NCDs and LCDs, scope of practice, accreditation standards, new technology, and screening mechanisms in order to integrate OCST into the provision of sleep medicine and avoid potential pitfalls. 

Create your legacy: join our team

Portland, Oregon

At Legacy Health, our legacy is doing what’s best for our patients, our people, our community and our world. Our fundamental responsibility is to improve the health of everyone and everything we touch - to create a legacy that truly lives on. Ours is a legacy of health and community. Of respect and responsibility. Of quality and innovation. It’s the legacy we create every day at Legacy Health. And, if you join our team, it’s yours.

Supervisor, Sleep Disorders Center - Legacy Good Samaritan Medical Center At Legacy Good Samaritan is currently recruiting for a Supervisor in the Sleep Disorders Center who, under the direction of the department manager, will be responsible for the day to day site-specific supervision of staff as well as all clinical and quality improvement activities. This is a highly specialized and technically knowledgeable practitioner that provides operational support to the Department Manager.

In addition to exceptional clinical and communication skills, the ideal candidate will: • Coordinate, teach and perform sleep diagnostic procedures and provide support to patients, staff and physicians.

• Assist in maintenance of current AASM accreditation as well as Joint Commission DME accreditation.

• Participate as a member of the health care team in cooperation with and under the direction of the Manager.

• Must hold current Oregon Polysomnograper License and BRPT Registry as a Polysomnography Technologist (R.PSG.T) with a minimum of 2 years’ experience in the field of Sleep Disorders.

• Minimum one year experience as a specialist or lead in the area of expertise.

Located in the heart of Northwest Portland, Legacy Good Samaritan Medical Center first opened its doors in 1875.

Today, it is a nationally acclaimed medical center specializing in the diagnosis and treatment of cancer, eye disease, complete heart and vascular care, rehabilitation, weight management and kidney transplantation.

As a nationally known and respected health care provider, Legacy Health offers an outstanding work environment, competitive salary and comprehensive benefits. Learn more about us and apply to job #12-7798 on our website at www.legacyhealth.org/jobs. For questions, please contact Maria Gonzalez at 503-415-5982 or toll free, 866-888-4428. Email: mgonzale@lhs.org. AA/EOE

www.legacyhealth.org/jobs A2 Zzz 22.1 | March 2013

27

TECHNICAL CORNER: THE EVOLVING DEFINITION OF HYPOPNEA: DESATURATIONS, AROUSALS, BOTH OR EITHER?

By Richard S. Rosenberg, PhD

It wasn’t that long ago that Medicare required 30 apneas recorded during a sleep study to qualify a patient for treatment with continuous positive airway pressure (CPAP). Twenty-nine apneas were not enough, and hypopneas were not considered.

Consider the event in Figure 1. I refer to it as an event because there is a clear change in breathing in the middle of this tracing.

There is a decrease in the amplitude of the nasal pressure signal and a flattening of the waveform. Snoring is evident, and it ends with an arousal. It is clearly different from the breathing pattern in the remainder of the tracing. But there is little if any change in oxygen saturation associated with the event. Prior to October, 2012, this event would be scored as a hypopnea only in centers where rule 4B, the alternative hypopnea scoring rule was used. It would be scored as a respiratory effort-related arousal (RERA) in centers where RERAs were scored and rule 4A, the recommended hypopnea scoring rule, was used. And in some centers it would not be scored at all.

Respiratory scoring was not part of the 1968 Rechtschaffen and Kales scoring manual. Block and colleagues are credited with the first definition of hypopnea in 1979 as a period of shallow breathing causing oxygen desaturation. The first attempt to define the spectrum of sleep related breathing events was the so-called “Chicago Consensus,” published in 1999. This defined an apnea hypopnea event as a clear decrease (> 50%) of a valid measure of breathing during sleep lasting 10 seconds or a clear amplitude reduction of a validated measure of breathing during sleep that does not reach the above criterion but is associated with either an oxygen desaturation of >3% or an arousal and lasting more than 10 seconds. The Consensus group felt that differentiation between apnea and hypopnea was not necessary.

The Consensus was never generally accepted, in part because thermal flow sensors and expired CO2 monitors were not considered part of the “valid measure of breathing” requirement.

Medicare was, at this point, still wedded to the 30 apnea rule and using the new criteria would require separate scoring rules for the elderly and young adults.

Drawing on data from the Sleep Heart Health Study, Meoli RICHARD S. ROSENBERG, PHD

The 2007 American Academy of Sleep Medicine (AASM) Scoring Manual revised the definition of hypopnea, allowing as an alternative rule 4B and the possibility of scoring hypopnea events without oxygen desaturation. In the accompanying review, Redline and colleagues cited reliability of scoring as a factor in the construction of a definition, noting that neither oxygen desaturations nor arousals were highly correlated with most outcomes measures. Proponents of oxygen desaturation battled with arousal proponents and the compromise was that 2 definitions were included in the scoring manual, a recommended and an alternative hypopnea scoring rule. A definition for RERAs was provided, but scoring of these events was considered optional. Furthermore, the International Classification of Sleep Disorders, Second Edition includes all “scoreable” respiratory events in the definition of the obstructive sleep apnea syndrome.

Dr. Richard Berry had the task of finding a consensus for the latest revision of the AASM Scoring Manual. He describes the final result as follows: Although there were dissenters, the task force reached consensus on a definition of a hypopnea rule in adults using a 30% drop in the nasal pressure excursion for 10 seconds or greater associated with ≥ 3% desaturation OR an arousal. The majority of the task force felt that a hypopnea definition based only on desaturation would result in misdiagnosis of some patients in whom respiratory events fragment sleep but result in minor drops in the SpO2.

Admittedly the evidence is poor, but there is some evidence for an association between oxygen desaturation and cardiovascular outcomes in patients with sleep apnea. There is also some evidence that arousals and sleep fragmentation with apnea are associated with decreased alertness during the day and diminished quality of life indicators. The Scoring Manual Task Force wrestled with these issues and elected to find either measure adequate for the identification of events. The final rule is based on consensus. Many if not all of the Task Force members had personal experience with patients who were decidedly symptomatic yet failed to meet the quantitative criteria for treatment. Many of the events previously scored as RERAs

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 Continued on Page 28

Richard S. Rosenberg, PhD, has been in the sleep field since 1972 and currently lives in Long Beach, Calif., where he works remotely as educational development coordinator for the American Association of Sleep Technologists.

and colleagues proposed a definition that included a 10 second event with a 30% reduction in amplitude of flow or effort and a 4% oxygen desaturation. The brief paper cited evidence of reliable scoring and association with cardiovascular outcomes.

Interestingly, this data was part of the Sleep Heart Health Study and used an out of center testing device for “polysomnographic” data collection. This definition was accepted by Medicare and allowed treatment of a much larger population of the elderly. It was quickly adopted by most private insurers as well.

ď&#x192;&#x160; Continued from Page 27

28

FIGURE 1

will now be scored as hypopnea and included in the apnea/ hypopnea index. Endorsing a definition that allows either oxygen desaturation or arousal will clearly increase the number of patients who qualify for treatment. Look at the event in Figure 1. I would call it an event, and my guess is that having frequent events like that would not be good for you. Dr. Christian Guilleminault has been saying this for decades. The field of sleep medicine must now use the new hypopnea scoring rule and collect evidence to demonstrate an association with outcomes and ability to score hypopnea events reliably.

5.

Iber C, Ancoli-Israel S, Chesson A, Quan SF, for the American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and associated events: Rules, terminology and technical specifications.

Westchester, IL: American Academy of Sleep Medicine, 2007.

6.

Redline S, Budhiraja R, Kapur V, et al. The scoring of respiratory events in sleep: Reliability and validity. J Clin Sleep Med 2007;3(2):169-200.

7.

American Academy of Sleep Medicine. International classification of sleep disorders: Diagnostic and coding manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine, 2005.

8.

Berry RB BR, Gamaldo CE, Harding SM, Marcus CL and Vaughn BV for the American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and associated events: Rules, terminology and technical specifications. In: Version 2.0. Darien, Illinois: American Academy of Sleep Medicine, 2012.

9.

Berry RB, Budhiraja R, Gottlieb DJ, et al. Rules for scoring respiratory events in sleep: Update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 2012;8(5):597-619.

REFERENCES: 1.

2.

Block AJ, Boysen PG, Wynne JW, Hunt LA. Sleep apnea, hypopnea and oxygen desaturation in normal subjects: A strong male predominance. N Engl J Med 1979;300(10):513-7.

The Report of an American Academy of Sleep Medicine Task Force. Sleep-related breathing disorders in adults: Recommendations for syndrome definition and measurement techniques in clinical research. Sleep 1999;22(5):667-89.

3.

Quan SF, Gillin JC. New definitions of sleep disordered breathing--not yet a mandate in clinical practice. Sleep 1999;22(5):662.

4.

Meoli AL, Casey KR, Clark RW, et al. Hypopnea in sleep-disordered breathing in adults. Sleep 2001;24(4):469-70.

10. Guilleminault C, Stoohs R, Clerk A, Cetel M, Maistros P. A cause of excessive daytime sleepiness: The upper airway resistance syndrome. Chest 1993;104(3):781-7 ď ś

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29 Journal of Clinical Sleep Medicine, Vol. 8, No. 6, 2012

Reprinted with permission of the American Academy of Sleep Medicine.

http://dx.doi.org/10.5664/jcsm.2278

“Why did my CPAP beat me Up?” bilateral Periorbital Ecchymosis Associated with Continuous Positive Airway Pressure Therapy Lourdes DelRosso, M.D.; David E. McCarty, M.D.; Romy Hoque, M.D.

SLEEP mEdICINE PEARLS

Louisiana State University School of Medicine, Department of Neurology, Division of Sleep Medicine, Shreveport, LA

gear without complication. CPAP compliance card report indicates 100% CPAP use > 4 h/day, average use 9 h/day, and no significant air leaks.

He now presents with 2 episodes of bruising around his eyes upon awakening following nocturnal CPAP use. He initially noticed bruising around the left eye which resolved over the course of one month. He did not pursue evaluation or treatment. Then he noticed new bruising around the right eye. He denied history of trauma, headaches, eye dryness or pain, vision changes, cough, sinus pain, or nasal discharge. He denied strenuous exercise or weight lifting. Significant air leak from his CPAP mask was not detected. He denied any other bleeding, including gums, urinary tract, or rectum.

T

he patient is a 63-year-old man with past medical history of hypertension, coronary artery disease, diabetes mellitus, hyperlipidemia, gastroesophageal reflux disease, and obstructive sleep apnea (OSA) diagnosed at the age of 58. Medications include aspirin 325 mg daily and clopidogrel 75 mg daily for 2 years without complication; clonazepam 1 mg daily, gemfibrozil 600 mg twice daily, metoprolol 12.5 mg twice daily, niacin 500 mg daily, ranitidine 150 mg twice daily, rosuvastatin 10 mg daily, and valsartan 160 mg daily. Two months ago he started using vitamin E 1000 international units per day and fish oil supplements. For 5 years he has been compliant with continuous positive airway pressure (CPAP) of 10 cm through a soft nasal pillow interface and soft head

figure 1—Periorbital ecchymosis associated with continuous positive airway pressure therapy for obstructive sleep apnea

Journal of Clinical Sleep Medicine, Vol. 8, No. 6, 2012

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 Continued on Page 30

The photograph on the left shows the patient with periorbital ecchymosis around the left eye, which resolved. The photograph on the right was taken one month later and showed a new right periorbital ecchymosis.

30

 Continued from Page 29

Journal of Clinical Sleep Medicine, Vol. 8, No. 6, 2012

Sleep Medicine Pearls

Physical examination revealed a large periorbital ecchymosis around the right eye (Figure 1). No scleral, skin, or nail bed petechial hemorrhages were noted. Pupils were round and reacted to light bilaterally. Visual fields were intact bilaterally. Fundoscopic examination revealed sharp discs bilaterally, with no evidence of intraocular or retinal hemorrhage.

Laboratory evaluation revealed no evidence of coagulopathy, thrombocytopenia, or Vitamin C deficiency (Table 1).

Aspirin and clopidogrel platelet inhibition assays showed normal platelet inhibitory responses to these medications.

Computerized tomography of the head was unremarkable, with no evidence of intracranial bleeding or basilar skull fracture.

Table 1—Laboratory Results Coagulation Labs Result Normal Range Platelet count 227 150-450 Prothrombin time (PT) 13.4 seconds 12-14.7 seconds Partial thromboplastin time (PTT) 29 seconds 24-37 seconds International normalized ratio 1 Antithrombin III 126% 80-123% Factor VIII level 122% 61-147% Von Willebrand 98% 50-140% Platelet inhibition for aspirin 399 ARU 0-550 ARU Platelet inhibition for clopidogrel 76% 40-60% Other Labs Aspartate transaminase (AST) Albumin Total bilirubin Blood urea nitrogen (BUN) Creatinine Vitamin C level

QUESTION What is the most likely mechanism for this patient’s bilateral periorbital ecchymosis? What is your treatment recommendation?

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A2 Zzz 22.1 | March 2013

Journal of Clinical Sleep Medicine, Vol. 8, No. 6, 2012

31 Journal of Clinical Sleep Medicine, Vol. 8, No. 6, 2012

L DelRosso, DE McCarty and R Hoque

2. Assessment of over-the-counter supplement use and their potential interactions with prescription medications is an important component of the sleep medicine history.

3. Vitamin E and fish oil supplements should be used with caution in patients on antiplatelet medications such as aspirin or clopidogrel.

4. Even low to moderate continuous positive airway pressures (CPAP) can lead to facial ecchymosis in patients on multiple antiplatelet medications or supplements.

ANSWER Initiation of Vitamin E and fish oil supplementation in combination with aspirin and clopidogrel use may have led to ecchymosis. We recommended discontinuation of Vitamin E and fish oil supplements.

Ecchymosis is an area of blood extravasation larger than 5 mm in size and is usually secondary to small or medium sized blood vessel trauma.3 In patients with either congenital or acquired coagulation defects, even trivial trauma may result in ecchymosis.

Petechial hemorrhages are smaller (< 2 mm) and typically due to damage to dermal capillaries. Causes of petechial hemorrhages include increased hydrostatic pressure in the capillary system (e.g., post-tussive or post-strangulation); infections (e.g., Rocky Mountain Spotted Fever); small vessel vasculitis (e.g., Henoch Schönlein Purpura); and poor capillary structural integrity (e.g., scurvy or amyloidosis). Confluent periorbital petechial hemorrhages may morphologically resemble ecchymosis as can be seen in amyloidosis.4 Our patient had no clinical features, or laboratory results suggestive of congenital or acquired coagulation defects; increased hydrostatic pressure; infection; vasculitis; or amyloidosis.

Complications associated with nasal CPAP therapy for OSA include nasal congestion; rhinorrhea; sneezing; mild to moderate epistaxis; and rarely severe epistaxis.1,2 To our knowledge, periorbital ecchymosis has not previously been reported as a complication of CPAP therapy.

We postulated that this patient’s recurrent periorbital ecchymosis was due to a combination of factors. Vitamin E has anticoagulant properties, possibly due to an inhibition of collagen-induced platelet activation and protein kinase C-dependent aggregation.5 Omega-3 fatty acids are also natural anticoagulants, and case reports indicate an increased bleeding risk when combined with other forms of anticoagulation.6 The combined antiplatelet activity of aspirin, clopidogrel, Vitamin E, and fish oil supplements, along with a CPAP induced elevation in central venous hydrostatic pressure, may have led to the development of periorbital capillary damage. The initial left periorbital ecchymosis followed by right periorbital ecchymosis may have been due in part to sleep position and/or positioning of the nasal CPAP nasal mask. Discontinuation of the Vitamin E and fish oil supplements resulted in complete resolution of the CPAP associated periorbital ecchymosis. The patient continued using CPAP with adequate compliance.

CITATION DelRosso L; McCarty DE; Hoque R. “Why did my CPAP beat me up?” Bilateral periorbital ecchymosis associated with continuous positive airway pressure therapy.

J Clin Sleep Med 2012;8(6):730-732.

REfERENCES 1. Pepin JL, Leger P, Veale D, Langevin B, Robert D, Levy P. Side effects of nasal continuous positive airway pressure in sleep apnea syndrome. Study of 193 patients in two French sleep centers. Chest 1995;107:375-81.

2. Strumpf DA, Harrop P, Dobbin J, Millman RP. Massive epistaxis from nasal CPAP therapy. Chest 1989;95:1141.

3. Girolami A, Luzzatto G, Varvarikis C, Pellati D, Sartori R, Girolami B. Main clinical manifestations of a bleeding diathesis: an often disregarded aspect of medical and surgical history taking. Haemophilia 2005;11:193-202.

4. Outteryck O, Stojkovic T, Launay D, Meignie-Ramon B, Vermersch P. Periorbital ecchymoses are not pathognomonic of the light-chain type of amyloidosis. Acta Derm Venereol 2007, 87:544-5.

5. Phang M, Lazarus S, Wood LG, Garg M. Diet and thrombosis risk: nutrients for prevention of thrombotic disease. Semin Thromb Hemost 2011;37:199-208.

6. Buckley MS, Goff AD, Knapp WE. Fish oil interaction with warfarin. Ann Pharmacother 2004, 38:50-2.

ACkNOWLEdgmENT The authors acknowledge Dr. Cesar Liendo for his advice with this manuscript.

SUbmISSION & CORRESPONdENCE INfORmATION Submitted for publication January, 2012 Submitted in final revised form March, 2012 Accepted for publication April, 2012 Address correspondence to: Lourdes DelRosso, M.D., Assistant Professor of Sleep Medicine, Sleep Medicine Program, Department of Neurology, Louisiana State University School of Medicine, Shreveport, Louisiana; E-mail: lordydel@yahoo.com

dISCLOSURE STATEmENT

CLINICAL PEARLS

This was not an industry supported study. The authors have indicated no financial conflicts of interest. 

1. Bruising associated with CPAP should prompt a search for a bleeding diathesis.

Journal of Clinical Sleep Medicine, Vol. 8, No. 6, 2012

732

A2 Zzz 22.1 | March 2013

NEW

AAST ONLINE LEARNING MODULES

The AAST Online Learning Center gives you new and affordable opportunities each month to earn continuing education credits (CECs) while you sharpen your professional skills and understanding.

Each narrated presentation allows you to learn at your own pace and from the convenience of your home or office.

VISIT THE AAST ONLINE LEARNING CENTER FOR THE LATEST LEARNING MODULES IN EACH OF THESE SERIES: CASE OF THE MONTH Each month a new module reviews a case dealing with topics such as proper and improper titration, difficult decisions associated with split-night studies, and normal sleep study variants. Tips on scoring and reporting are provided with each presentation.

Recent modules include: • REM Predominant Apnea • Split Night Study • OSA with Features of Cheyne Stokes Breathing • Pediatric Patient With Limb Movements

JOURNAL CLUB These learning modules will help you stay up to date on the latest developments in sleep technology and sleep medicine. Each module contains a video discussion with the author of a recent article published in a sleep journal. The full text of the article is included with purchase.

Recent modules include: • Inter-scorer Reliability Sleep Stage Scoring • APPLES Study • OCST in Truck Drivers • Effects of Sleep Deprivation

ADVANCES IN SLEEP TECHNOLOGY In October the AAST’s “Advances in Sleep Technology: OCST and the Future of Sleep Technology” course provided attendees with an overview of the latest advances in technology related to the diagnosis and treatment of sleep disorders. Lectures focused on implementing out-of-center sleep testing, equipment and device selection, long-term care of the sleep patient, outcomes tracking and future planning for sleep centers.

Several presentations from the course are now available as learning modules: • Human Resources & Staffing – Rita Brooks, RST, RPSGT • Policies and Triage - Shari Angel Newman, RPSGT, RST • Sleep Services Benefits – Bartley Bryt, MD, MPH • Standards of Practice & Insurance Standards – Laura Linley, RST, RPSGT, CRT • The Effects of Social Media and Communications – Jayme Matchinski, JD

American Association of Sleep T echnologist s

AAST

®

www.aastweb.org/learningcenter/home.aspx

33

In the Moonlight Q&A with Nisar Ashraf, BSRC, CRT-SDS, RPSGT, RST

“In the Moonlight” puts an American Association of Sleep Technologists (AAST) member in the spotlight, giving readers an opportunity to get to know one of their colleagues. This month A2Zzz asked Nisar Ashraf, BSRC, CRT-SDS, RPSGT, RST to complete the following statements. Nisar has been in the sleep field since 2000. He is the Clinical Services Manager for SleepMed, Inc. in Altamonte Springs, Fla. When I was young I wanted to grow up to be a…physician.

I decided to become a sleep technologist because…of my interest in sleep. I was introduced to it in my Respiratory program at Indiana University Purdue University Indianapolis (IUPUI).

I was fascinated by all of the EEG and different parameters we monitored on every patient.

I got my first job in sleep technology at…St. Francis Hospital in Indianapolis.

I became an AAST member because…I want to stay updated about upcoming sleep related news.

The website I visit most often is…www.aasmnet.org, www.brpt. org and www.news.yahoo.com.

The person whom I would most like to meet is…anyone who has an inspiring story to tell that makes us appreciate our surroundings.

The biggest change I have seen in the profession since I started is…reimbursement cuts, challenges in the sleep profession, home sleep tests versus in lab studies.

Words of advice I have for people who are new to the profession are: sleep is still a very rewarding career, do not hesitate to completely engulf yourself in sleep.

My professional goals for the next five years are…to grow my areas and do more intense sleep related lectures and physician training.

Sleep is…the best meditation. – Dalai Lama

The person who has had the greatest influence on my career is…my mentor Ben Thomas. I’ve been working with him since 2001. He owned his own Independent Diagnostic Testing Facility (IDTF) that was six beds when I joined his team. We quickly grew to 14 beds and ran seven nights a week.

The most challenging part of my profession is…reimbursement cuts depleting the quality of studies and specialists in the sleep profession.

September

2010 | Volume

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 Possib

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Insomnia

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Upper

ctive Oxide, Obstru mation Facilities for Sleep Airway Inflam Techniques Strategy and Management

 Nitric

The thing I like most about my profession is…helping people and hearing them say that they slept great and were dreaming while using CPAP.

 Risk  The

A, B, C of

 Second

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“DIY EEGT” Generation

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logists

The food I’m most likely to snack on while working is…trail mix.

For fun on days off from work I like to…relax and do some projects around the house.

My favorite TV show is…Gold Rush.

My favorite singer or musical group is…Andrea Bocelli.

A2 Zzz 22.1 | March 2013

Would you like to appear “In the Moonlight”? Send an e-mail to A2Zzz@aastweb.org.

Educational/Technical Order Form Educational Resources

Item#

AAST Sleep Technology Terms & Definitions Provides the profession with a consistent and accurate explanations of key terms that are used in the routine practice of sleep technology.

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Sleep Technology Self Assessment Exam Part I Prepare for the registry exam with this self-assessment tool, which is based on the AASM scoring manual and comprises 100 questions with a referenced answer key.

1011

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Sleep Technology Self Assessment Exam Part II Part II continues where Part I leaves off with an additional 100 questions and a referenced answer key.

1012

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Sleep Technology Self Assessment Exam Part III Part III contains 100 fully-referenced questions to help prepare for the RPSGT registry exam.

1013

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Normal and Abnormal Record Flashcards This set of 138 flashcards will help you review normal and abnormal records.

1020

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Registry Exam Flashcards, 2nd Edition This comprehensive set of 168 flash cards allows you to prepare for the registry exam anytime and anywhere.

1021

______

$30.00

$45.00

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Pediatric Flashcards, 1st Edition This innovative set of 50 flash cards will help you gain a better understanding of the unique aspects of pediatric sleep studies and pediatric sleep disorders.

1022

______

$20.00

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______

Technologistâ&#x20AC;&#x2122;s Guide to Performing Sleep Studies The Guide is an excellent introduction to sleep technology and can be used as a review text for those with sleep center experience.

2103

______

$40.00

$60.00

______

Bundle 1: Scoring Cardiac Events

4001-A2Z

______

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Bundle 2: PSG Scoring

4002-A2Z

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4003-A2Z

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$35.00

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Set: Includes Bundles 1-6

4100-A2Z

______

$120.00

$180.00

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A2Zzz Article Bundles The AAST has developed six A2 Zzz Article Bundles containing articles about specific topics and a quiz for each article. After reading each of the articles and taking the quizzes, individuals can earn 3.00 AAST Continuing Education Credits (CECs) per bundle by submitting an AAST CEC Request Form to the national office. The bundles are available as a set or individually.

Advances in Sleep Technology Webinar Series This new professional educational opportunity provides individuals with 1.00 CEC for each webinar topic.

Item#

Qty.

Item#

Qty.

3000 ______ Emergencies in the Sleep Center

3008 ______ Inter-scorer Reliability and Gold Standard Scoring

3001 ______ Central and Complex Sleep Apnea

3009 ______ Foundations of Clinical Research - Research Project Planning

3002 ______ Parasomnias

3010 ______ Use of Pulse Transit Time During Sleep Monitoring

3003 ______ Making a CPAP Clinic Work in Your Facility

3011 ______ State Sleep Societies/State Legislative Issues

3004 ______ Developing Formal Sleep Education Programs

3012 ______ Truckers and Road Safety

3005 ______ Pediatric Sleep Medicine & Technology

3013 ______ Sleep in an Aging Population

3006 ______ Seizure Disorder

3014 ______ Advanced Signal Processing

3007 ______ EKG Complex Arrhythmias

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Total Webinar Qty. ______

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______

Name: ____________________________________ Member # ___________________________Subtotal (page 1): ________

Fundamentals of Sleep Technology - Preparing for Certification - 1st Edition The Fundamentals of Sleep Technology - Preparing for Certification is a review course designed to help sleep professionals study for the registry exam and features real-time video alongside an electronic presentation. The course has four package options - each has the same content and the same total AAST CEC value, but it’s divided to suit your needs.

Item#

Qty.

Members

Non-Members

Total

Full Course (2010) Contains the entire course in two CD-ROMs. Includes one course book and the Self Assessment Exam Part II. Earn up to 12.00 AAST CECs.

1200

______

$200.00

$300.00

______

Full Course - Institutional (2010) The Institutional Version is intended for sleep center managers. It includes five copies of the course and five copies of the course book.

1201

______

$625.00

$750.00

______

Collections (2010) These versions break up the course into three CD-ROMs, available separately. 4.00 AAST CECs each.

Introduction to Sleep Medicine

1202

______

$75.00

$115.00

______

Performing and Scoring the PSG

1203

______

$75.00

$115.00

______

Treatments and Other Topics

1204

______

$75.00

$115.00

______

Sets (2010) These versions break up the course into six CD-ROMs, available separately. 2.00 AAST CECs each.

Introduction to Sleep Medicine

1205

______

$40.00

$60.00

______

Physiology of Sleep

1206

______

$40.00

$60.00

______

Performing the PSG

1207

______

$40.00

$60.00

______

Scoring the PSG

1208

______

$40.00

$60.00

______

Pediatrics in Sleep

1209

______

$40.00

$60.00

______

Treatment and Other Topics

1210

______

$40.00

$60.00

______

AAST 10-20 Head Measurement Chart This tool assists sleep technologists with converting head measurements to determine electrode placement.

1150

______

$5.00

$7.50

______

Manual Titration of PAP in Patients with OSA & Sleep Related Sleep Disturbances This reference & training tool is designed to provide quick access to CPAP & BiPAP protocols.

1160

______

$5.00

$7.50

______

2010 Salary and Benefits Survey This 81-page survey provides compensation and benefits information received from 214 accredited sleep centers throughout the U.S.

1120

______

$80.00

$130.00

______

Artifact & Troubleshooting Guide This unique guide contains examples of 29 artifacts that can occur during polysomnography, including illustrations, descriptions, causes and solutions.

1131

______

$20.00

$30.00

______

Technical References

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Promotional Item Order Form Sale extended while supplies last.

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Show you care! Makes a great PSG Technologist Appreciation Week gift.

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37

CERTIFICATION UPDATE:

From the Board of Registered Polysomnographic Technologists BRPT Names Theresa Krupski President-Elect of the Board of Directors The Board of Registered Polysomnographic Technologists (BRPT) named Theresa Krupski, RPSGT, RRT, President-Elect of the Board of Directors. Her two-year term as President will begin in January 2014, following the completion of current President Cindy Altman’s term. Krupski has been a member of the BRPT Board since 2011 serving as Chair of the Scholarship Committee, as well as an active participant on the Exam Development Committee. Krupski is the Neurodiagnostic Technology program director at the Community College of Denver in Denver, Colorado.

“It’s an honor to be elected President-Elect of the BRPT Board,” said Theresa Krupski. “I’ve thoroughly enjoyed working with, and learning from, this dedicated Board of Directors. Their leadership and innovative approach to effectively serving our credential holders, coupled with their devotion to the field, is remarkable.”

Said BRPT President Cindy Altman, RPSGT, R. EEG/EP T., “Theresa has served on the Board through a busy and dynamic period – she is well-positioned to take the helm in 2014. Her experience in the education arena will serve the organization well as it continues to build on these offerings. This year, I look forward to working even more closely with Theresa as we enhance our advocacy efforts while strengthening the RPSGT credential.”

In addition, BRPT welcomes Deb Kovacs-Sturdevant, RPSGT, RRT and Helen S. Driver PhD, RPSGT, DABSM, Somnologist, of Canada to the Board. Kovacs-Sturdevant is the Manager of the Sleep Center at Mercy Health Anderson Hospital in Cincinnati, Ohio. Driver manages a 6-bed sleep disorders laboratory at Kingston General Hospital and is an adjunct Assistant Professor in the Department of Medicine at Queen’s University. Full biographies of all BRPT Board members can be found at www.brpt.org.

Reminder: RPSGT Exam Eligibility Changes – Effective March 1 In an effort to make the BRPT examination requirements for clinical experience more flexible for those working adjustable schedules, effective March 1, 2013 the BRPT changed how candidates track the clinical experience requirement. Also, to meet clinical experience requirements in states where onthe-job training is not permitted, BRPT no longer requires paid clinical work experience. However, clinical experience remains a cornerstone of an applicant’s training, through Pathways 1, 2 and 4 for the RPSGT exam. In addition, the BRPT is adding an additional pathway – Pathway 5 – geared

toward international candidates performing polysomnography after completion of post-secondary education required for practice in their country. More information can be found here: http://www.brpt.org/default.asp?contentID=212 New RPSGT And CPSGT Exam Blueprints, AASM Scoring Manual Updates, Effective July 1st New exam blueprints for both the RPSGT and CPSGT exams can be found on the BRPT website. The new blueprints are the result of the recent Job Task Analysis ( JTA). RPSGT and CPSGT exams will be built against the new exam blueprints and the new AASM scoring rules and will be implemented on exams effective July 1. Revised candidate handbooks and study guides will be available in the coming months.

Third Andrea Patterson Scholarship Winner Announced Congratulations to Amanda Perry, of Conway, Arkansas who is the winner of the third Andrea Patterson Memorial Scholarship.

Perry is a student enrolled in the Sleep Technology program at Baptist Health Schools in Little Rock, Arkansas.

Reinforcing her love of education, Perry worked for 12 years as an administrative assistant at St. Joseph Catholic School, a middle school in her hometown of Conway, Ark. In 2011, she began researching career choices in the medical field hoping to find a good fit. Said Amanda Perry, “The more I learned about the field of sleep technology, the more excited I got. Part of my application process for the sleep technology program at Baptist Health required an observation at the Baptist Medical Center Sleep Lab. At that moment, I knew I was squarely on the right path. I’m honored to receive a scholarship in the name of Andrea Patterson and everything she represented.”

Perry is expected to graduate in June of 2013 after which she plans to take the RPSGT examination. She is a member of the Sleep Professionals of Arkansas association and an active member of the St. Joseph Catholic Church, serving on its community assistance program committee.

The Andrea Patterson Memorial Scholarship Program awards a $2,500 tuition grant each year to a promising student of polysomnography. Scholarship applicants must be enrolled in or accepted by a CAAHEP-accredited program in PSG or a CoARC-accredited program with a PSG add-on. The application window for the fourth annual Scholarship will open soon – stay tuned for details! 

A2 Zzz 22.1 | March 2013