A2zzz vol 26 number1

March 2017 | Volume 26 | Number 1

Residual Sleepiness in OSA: Possible Factors Full-Face Masks: A Full Can of Worms Educating About "Orderly Sleep" is as Important as Educating About Sleep Disorders Comparison of CPAP versus APAP If The Eyes Have It, You May Have It...OSA That Is! The New Sleep Gadgets: What Technologists Need to Know

A Publication of the American Association of Sleep Technologists

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FROM THE EDITOR

Rita Brooks, MED, RST, RPSGT, REEG/EPT hope this issue finds you and yours doing well, and like me I am sure you are wishing spring would just get here! Well, the spring issue of A2Zzz is here, so maybe that will somehow move it along.

I

This issue of A2Zzz has some wonderful submissions, as always. We start with an intriguing article from Regina Patrick about the fact that some people who are treated for obstructive sleep apnea (OSA) inexplicably continue to struggle with residual sleepiness, although they are following their treatment protocol correctly. Thom Russel presents a case study on the limitations of full-face continuous positive airway pressure (CPAP) masks that informs technologists and physicians they should be aware of potential difficulties when using them and be prepared to reevaluate patients who may experience difficulties.

Brendan Duffy has contributed two articles for this issue; the first reminding us as sleep educators that it’s important to educate not just about sleep disorders, but also about basic sleep hygiene, and the second reviewing some interesting eye conditions that may be related to OSA in patients with either condition. Krystle Minkoff provides a brief overview of the differences in efficacy of CPAP versus APAP. Our final article is a broad overview of some of the many new personal sleep monitoring products by Tamara Sellman. There are many new products out there, and Tamara reminds us, as sleep technologists, that we should have an understanding of what these new DIY healthcare tools can (or can’t) do to help a patient monitor and evaluate their sleep.

On another exciting note, this year’s AAST Annual Meeting will be held in Boston. The Program Committee has developed a diverse program, and once again this year, there will be two tracks Sunday afternoon - one covering management topics and the other focused on pediatrics.

For those looking for regional AAST activities, the 2017 Technologist Course on March 23, 2017, will offer great networking and learning opportunities. Visit the Southern Sleep Society website for more information.

You are also invited to join the AAST for collaborative events being presented at FOCUS in May in Orlando. The AAST is offering the Sleep Center Essentials Course at FOCUS on May 4th and a Fundamentals Workshop on May 7. Learn more about both of these opportunities and register for one or both of them on the

MARCH 2017 | VOLUME 26 NUMBER 1

TABLE OF CONTENTS

From the Editor.................................................................3 From the President............................................................6 Continuing Education Credit Offering..........................7 Ask the President..............................................................8 Residual Sleepiness in OSA: Possible Factors......... 9-11 Full-Face Masks: A Full Can of Worms.................13-14 Educating about "Orderly Sleep" is as Important as Educating About Sleep Disorders.................................15 Comparison of CPAP versus APAP.............................16 If The Eyes Have It, You May Have It...

OSA That Is!.....................................................................17 The New Sleep Gadgets: What Technologists Need to Know............................................................19-22 In the Moonlight: Rui de Sousa.....................................23 Certification Update (BRPT).........................................24 AAST spring course page.

I hope to see you all at one of these AAST educational programs in the spring, or in June at the Annual Meeting in Boston.

As always, I wish you the best.

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A2 Zzz 26.1 | March 2017

Submit an original article for publication in A2Zzz. See page 4 for details.

4

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

ABOUT A2Zzz

A2Zzz is published quarterly by the American Association of Disclaimer: The statements and opinions contained in articles and Sleep Technologists (AAST), 2510 North Frontage Road, Darien, editorials in this magazine are solely those of the authors thereof and IL 60561. not of the American Association of Sleep Technologists (AAST); the American Academy of Sleep Medicine (AASM), which provides Learning Objectives: Readers of A2Zzz should be able to do the management services for the AAST; or of either organization’s following: officers, regents, members or employees. The appearance of products • Analyze articles for information that improves their under- and services, and statements contained in advertisements, are the standing of sleep, sleep disorders, sleep studies and treatment sole responsibility of the advertisers, including any descriptions of effectiveness, quality or safety. The Editor; Managing Editor; AAST; options AASM; and each organization’s officers, regents, members and • Interpret this information to determine how it relates to the employees disclaim all responsibility for any injury to persons or practice of sleep technology property resulting from any ideas, products or services referred to in • Decide how this information can improve the techniques articles or advertisements in this magazine. and procedures that are used to evaluate sleep disorders patients and treatments Mission: The American Association of Sleep Technologists • Apply this knowledge in the practice of sleep technology

(AAST) promotes sleep wellness and leads the sleep technology profession through education, resources, and advocacy.

Submissions: Original articles submitted by AAST members and Vision: The American Association of Sleep Technologists (AAST) by invited authors will be considered for publication. Published will play a key role in setting the standard for professional excellence articles become the permanent property of the AAST. in the evolving practice of sleep healthcare.

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.

Purpose: To provide a voice for the professionals who ensure the safe and accurate assessment and treatment of sleep disorders.

2510 North Frontage Road Advertising: Advertising is available in A2Zzz. Please contact the Darien, IL 60561 AAST national office for information concerning A2Zzz rates and Phone: (630) 737-9704 Fax: (630) 737-9788 policies, or find more details online at www.aastweb.org.

E-mail: A2Zzz@aastweb.org | Web: http://www.aastweb.org © 2017 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/publication-info. 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

Rui de Sousa, RPSGT, RST Brendan Duffy, RST, RPSGT Laura Linley, CRT, RST, RPSGT Krystle Minkoff, RPSGT, RST Thom Russell, RRT (ADV); PSGT Tamara Sellman, RPSGT, CCSH

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 26.1 | March 2017

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6

FROM THE PRESIDENT

By Laura Linley, CRT, RST, RPSGT

WHAT’S NEXT?

AAST PRESIDENT LAURA LINLEY, CRT, RST, RPSGT

On behalf of the American Association of Sleep Technologists (AAST) board of directors, I would like to take this opportunity to communicate some very important information about the future of our organization. It is with great excitement that I announce the AAST will transition headquarters and staff management to SmithBucklin as our new management firm.

Let me explain a bit about the importance of this announcement.

Since 2003, AAST has operated under a management contract with the American Academy of Sleep Medicine (AASM). During that time, we have experienced many positive changes, including a significantly improved operational and financial foundation.

But moving forward, it became apparent to the board that to continue growing and meeting the rapidly changing and increasingly complex needs of our membership, we needed to ensure that our association was taking every step to become more responsive. We realize that you—our members—have high expectations of our organization’s value and relevance, and have many time pressures that can make it challenging to find time for day-to-day, operational volunteer duties.

Following a five-month discovery process during which our board’s executive committee identified and thoroughly vetted many new options for management companies, a unanimous decision was reached to transition to SmithBucklin.

AAST’s entire leadership team is very excited about the prospect of a long-term partnership with SmithBucklin; one that is built on shared values and culture. SmithBucklin has 65 years of experience serving independent non-profit associations, including approximately 30 other healthcare-related societies and associations. Our board conducted reference checks during the proposal process and was impressed with SmithBucklin’s depth and breadth of resources, proven practices and respected thought leadership.

In fact, we will be holding a membership town hall conference call on March 16th to outline key points and address any questions that our members may have about the transition. Look to our website for more information on this town hall conference call, as well as more information on SmithBucklin. And of course, if you have additional questions or concerns at any time, please do not hesitate to contact me directly.

On behalf of the entire board of directors, I would like to thank the AASM staff members who have served the Association well for many years and provided a solid foundation on which we can build.

I want you to know that the entire AAST board approached this decision to partner with SmithBucklin very thoughtfully and critically. We strongly believe that this new partnership is the right move for us, and will allow us to serve our current members at the highest level possible. As for what this means for potential new members; there has never been a better time than now to join AAST. Exciting things are in store!

In closing I must say that serving as the 2015-2017 president of the AAST has been both an honor and a pleasure. To my fellow board members, thank you for both your dedication and service to our organization. To our amazing committee members, I know sometimes it can be a thankless job, but please know that the AAST could not do what we do without your hard work and dedication, and we really do appreciate your service to the organization. Lastly, thank you to all of our AAST members. It was an honor getting to know so many of you at various events this year and I hope to stay in touch going forward.

I am excited to continue to support Rita Brooks and the entire 2017 board as they continue to advance the mission and vision of the AAST.

Now, here is what this means for you at this very moment: business as usual. During this transition, every effort will be made to continue operating AAST in the same manner as always. We will continue to keep you up to date on our progress, with contact information for our new AAST headquarters office and staff coming your way very soon.

A2 Zzz 26.1 | March 2017

7

CONTINUING EDUCATION CREDIT OFFERING INSTRUCTIONS FOR EARNING CREDIT

AAST members who read A2Zzz and claim their credits online 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 claim your credits online. You must go online to claim your credits by the deadline of June 8, 2017. After the successful completion of this educational activity, a confirmation letter acknowledging that you have earned 2.00 AAST CECs will be sent 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.

CLAIM CEC CREDITS FOR A2Zzz ONLINE

Claiming continuing education credits (CECs) by reading A2Zzz is now easier than ever: AAST Members can claim credits online through the AAST website – no need to mail, email or fax your completed evaluation form! Visit the AAST website and claim your CECs today!

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 go online to claim your CECs by the deadline of June 8, 2017.

Read and evaluate four of the following articles to earn 2.0 AAST CECs: Page # Residual Sleepiness in OSA: Possible Factors...................................................................................................................... 9-11 Objective: Understand why residual sleepiness occurs in treated obstructive sleep apnea patients.

Full-Face Masks: A Full Can of Worms............................................................................................................................. 13-14 Objective: Identify limitations of full-face masks.

Educating about "Orderly Sleep" is as Important as Educating About Sleep Disorders............................................................. 15 Objective: Understand the importance of education about basic sleep hygiene.

CPAP Versus APAP.............................................................................................................................................................. 16 Objective: Understand the difference between CPAP and APAP. If The Eyes Have It, You May Have It...OSA That Is!.............................................................................................................. 17 Objective: Learn about some interesting eye conditions that may be related to obstructive sleep apnea (OSA).

The New Sleep Gadgets: What Technologists Need to Know.............................................................................................. 19-22 Objective: Learn about what personal sleep monitoring products can and can't do to help patients monitor and evaluate their sleep.

A2 Zzz 26.1 | March 2017

8

ASK THE PRESIDENT - WHAT CAN ATTENDEES EXPECT FROM THE 39TH ANNUAL MEETING?

By Laura Linley, CRT, RST, RPSGT

W

e have been busy planning educational programs. We are excited to move forward with the AAST Annual Meeting as it is the longest running professional conference for sleep technologists. This year the 39th Annual Meeting will be held in Boston, MA.

however, AAST CECs and/or AARC CRCE contact hours are not available for the SLEEP 2017 sessions.

Once again this year, on Sunday afternoon, the Annual Meeting will offer two tracks in the afternoon—one covering management topics and one covering pediatric topics. Attendees are welcome to attend all sessions, and may pick and choose from both tracks to meet their individual interests and needs.

Sunday, June 4, 2017...................................................7.75 CECs Monday, June 5, 2017..................................................6.75 CECs Tuesday, June 6, 2017 .................................................6.75 CECs

The management track includes sessions G05: Establishing a Sleep Program from In-Patient to Home with Sunil Sharma, MD; G07: Advancing your Career to Remain Competitive in Sleep Technology with David Wolfe, MSED, RRT-SDS, RST, RPSGT, Gary Lavalette, CRT, RST, RPSGT and Eileen Leary, MS, RPSGT, RST; G09: Sleep Facility Accreditation and Management with Adam Bennett, MBA, BSRC, RRT and G11: Sleep Forensics with David Wolfe, MSED, RRT-SDS, RST, RPSGT. The pediatric track includes sessions G06: Pediatric Scoring Review and Updates with Amber Allen, BA, RPSGT, RST; G08: Problem- Based Learning through Pediatric Case Studies with Thomas Kinane, MD; G10: Titrating the Pediatric Patient: What to Know with Patrick Sorenson, MA, RPSGT and G12: Placing Electrodes on the Pediatric Patient with Colin Massicotte, RPSGT. As always, I anticipate all of these sessions will present excellent learning opportunities for both new and seasoned sleep technologists and sleep program clinicians!

As part of the Annual Meeting registration fee, AAST attendees will also have access to the SLEEP 2017 Exhibit Hall, which showcases booth displays of the latest offerings from pharmaceutical companies, equipment manufacturers, medical publishers, software companies and more. Registration for the AAST Annual Meeting allows you to also attend SLEEP 2017 general sessions;

Meeting attendees can earn up to 21.25 Continuing Education Credits (CECs). The following is a breakdown of CECs by day:

In addition to our Annual Meeting June 4-6, our Spring 2017 Technologist Course and our Sleep Center Essentials Course in May will offer great networking and learning opportunities.

The AAST is teaming up with the Southern Sleep Society to host the Spring 2017 Technologist Course, a one-day event for allied health professionals seeking insight to help them advance their skill sets. Join us on March 23rd, 2017 for this valuable, eight-hour course. Visit the Southern Sleep Society website for more information.

For the first time the AAST is participating in a collaborative event with Focus Publications & Conferences Inc. this spring on May 4 & 7, 2017 in Orlando, FL. Learn more on the AAST website on the spring course page. We are offering 2 courses during this event. Are You Up to Date and Safe to Practice? (May 4, 2017) is geared toward sleep professionals, especially managers, who need a clear understanding of how quality, safety and regulatory compliance issues impact sleep center operations; and an AAST Technologists Fundamentals Workshop (morning of Sunday May 7, 2017) will cover vital topics such as instrumentation and 10-20 measurements.

I hope you will stop by and introduce yourself to me at one of these upcoming meetings. Being part of these education events has been one of the highlights of my term as president. I am grateful for the mentoring and endless volunteer hours of the board I work with and all the committee members and volunteers that make these kinds of programs possible.

LAURA A. LINLEY, CRT, RST, RPSGT Laura A. Linley is VP of Clinical Operations for Advanced Sleep Management, LLC. She has implemented DME in an IDTF and MultiSpecialty Clinical settings and presently sits on the AAST Board of Directors and is the Board Liaison for the CoA PSG.

A2 Zzz 26.1 | March 2017

9

RESIDUAL SLEEPINESS IN OSA: POSSIBLE FACTORS

By Regina Patrick, RPSGT, RST

I

n obstructive sleep apnea (OSA), the upper airway tissues intermittently collapse into the airway during sleep and block airflow. The blood oxygen level falls and ultimately triggers a brief arousal during which a person takes a few deep quick breaths to restore the oxygen level. The arousals disrupt sleep, which results in excessive daytime sleepiness. The most effective treatment for OSA is continuous positive airway pressure (CPAP) therapy in which pressurized air is blown through the upper airway to prevent its collapse. By preventing apnea-related arousals, CPAP treatment should ideally resolve daytime sleepiness in all patients. However, approximately 10–13 percent of treated OSA patients continue to experience residual sleepiness,1-3 although noncompliance with CPAP therapy, insufficient CPAP pressure, improper sleep hygiene, and undiagnosed sleep disorder have been ruled out as causes of the residual sleepiness. To increase daytime wakefulness, OSA patients with residual sleepiness are often prescribed wake-promoting drugs such as modafinil. Even with wake-promoting medications, daytime sleepiness persists in some CPAP-treated OSA patients, which suggests that other factors could be contributing to the sleepiness.

In PET, glucose molecules containing the isotope fluorine-18 (i.e., fluorodeoxyglucose) are used to detect metabolically active areas of the brain—the more active a brain tissue, the greater the uptake of fluorodeoxyglucose. Based on this phenomenon, Antczak noted that the PET scans revealed a greater degree of decreased activity (as reflected by reduced fluorodeoxyglucose uptake) in the frontal area in OSA patients with residual sleepiness, compared to OSA patients without residual sleepiness. Antczak proposed that the more substantial decreased activity in the frontal regions may explain residual sleepiness in treated OSA patients.

Many brain neuroimaging studies4-6 have compared differences in the brains of people with and without OSA. In such studies, changes in the function of the frontal lobe and gray matter loss in the frontal and parietal cortex, right hippocampus, and deep cerebellar nuclei were noted in people with OSA. However, these studies did not investigate differences in the brains of OSA patients with and without residual sleepiness. In 2007, Antczak et al.7 were the first investigators to use a brain imaging technology—positron emission tomography (PET)—to investigate whether residual sleepiness in OSA patients is associated with brain injury and whether this injury is limited to certain areas in the brain. Antczak compared OSA patients with and without residual sleepiness. All patients had been on CPAP therapy for at least one year. In the patients with sleepiness, other causes of residual sleepiness had been ruled out before the study.

For example, in a mouse model of OSA-induced sleep disruption, researchers Yan Zhu et al.8 demonstrated a significantly reduced number of locus ceruleus neurons and orexinergic neurons (both of which promote wakefulness) in mice that had been exposed to chronic sleep disruption for 14 weeks, compared to the number in mice that had not undergone this treatment. They believed that this degeneration may be related to metabolic stress occurring in the mitochondria (i.e., intracellular structures that are involved in cellular respiration and energy utilization), as reflected by the decreased level of antioxidant enzymes and increased level of tumor necrosis factor-alpha in the neurons.

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

Ying Xiong and colleagues9 used diffusion tensor imaging (DTI) to compare differences in the white matter of the brains of CPAP treatment-compliant OSA patients with and without residual sleepiness. Diffusion tensor imaging creates images by detecting water molecule movement. Water molecules travel in a straight line along a nerve fiber. Therefore, a disruption in this flow (i.e., diffusivity) indicates neuronal damage. The DTI scans revealed that the sleepy patients had a greater number of disrupted nerve fiber tracts (as indicated by a larger mean diffusivity value) in the white matter, compared to the non-sleepy patients. Fiber tracts involved in wakefulness were altered in basal structures of the brain (e.g., internal and external capsule, corona radiata, corpus callosum, and sagittal stratum). Xiong concluded that differences in the degree of disruption in white matter may explain why

A2 Zzz 26.1 | March 2017

 Continued on Page 10

REGINA PATRICK, RST, RPSGT

Since the Antczak study, some factors that have been investigated in the wake-activating pathways in the brain of OSA patients with and without sleepiness are neuronal degeneration, metabolic alterations, and intermittent hypoxia/reoxygenation-induced neuronal damage. The findings of various studies suggest the existence of OSA subtypes, which would explain the different responses to CPAP treatment, and suggest possible new therapeutic targets for treating residual sleepiness.

ďƒŠ Continued from Page 9

10 CPAP treatment-compliant OSA patients can have different treatment responses with regard to sleepiness.

compared to the knockout mice. When the mice were subjected to learning tasks, the intermittent hypoxia-exposed mice performed worse than their control counterparts, whereas learning Zhu et al.10 investigated the impact of repeated hypoxia/reoxygen- was unaffected in knockout mice, compared to their counterparts.

Nair et al.12 concluded that oxidative stress responses induced ation episodes on wake-activating neurons in a mouse model of sleep apnea. Zhu exposed mice to eight weeks of hypoxia/reoxyby intermittent hypoxia during sleep are mediated by excessive genation episodes. An examination of their brain tissues revealed NADPH oxidase activity. injury to adrenergic locus ceruleus neurons and dopaminergic ventral periaqueductal gray neurons (which are involved in the Modafinil and armodafinil are the only wake-promoting drugs control of respiration). However, nearby cholinergic, histaminerapproved to treat residual sleepiness in people with OSA. Their gic, orexinergic, and serotonergic neurons involved in wakefulness mechanism of action is unknown, but they may exert their effects remained undamaged. In another investigation in the same study, by modulating wake-promoting substances such as glutamate, Zhu focused on the role of the enzyme nicotinamide adenine gamma-aminobutyric acid, histamine, hypocretin, and the dinucleotide phosphate (NADPH) oxidase in the wake-promotmonoamines. Some adverse effects of modafinil and armodafinil ing regions of the brain. This enzyme is involved in the generation are headache, dizziness, upper respiratory tract infection, nausea, of reactive oxygen species, molecules that have a role in the diarrhea, nervousness, anxiety, agitation, dry mouth, insomnia, oxidative injury of tissues. On examining brain tissues, Zhu found chest pain, and fast/pounding/irregular heartbeat. Modafinil and subunits of the NADPH oxidase molecule in wake-promoting armodafinil also have the potential for dependence, although they catecholaminergic neurons (i.e., neurons producing or activated by are less addictive than other stimulants such as amphetamines. catecholamines such as adrenaline, noradrenaline, and dopamine), which may explain nerve injury. In another investigation in the Treatment approaches that can avoid these drawbacks while study, Zhu treated a group of mice with the NADPH oxidase improving sleep are needed. Pharmacological agents targeting inhibitor apocynin throughout the hypoxia/reoxygenation specific systems involved in wake such as NADPH oxidase exposure and found that this treatment protected catecholamiproduction may provide new therapeutic strategies to treat nergic neurons. Based on these findings, Zhu suggested that residual sleepiness in OSA patients.12 For example, NADPH certain wake neurons, particularly catecholaminergic neurons, oxidase inhibitor drugs could provide neuroprotection of wake-acmay become persistently and then permanently damaged after tivating neurons. Continued investigations may soon clarify the long-term exposure to hypoxia/reoxygenation. Zhu further factors that contribute to residual sleepiness in treated OSA proposed that severe OSA in humans may destroy catecholamin- patients and provide more treatment options for these patients. ergic wake neurons, and thereby result in residual sleepiness.

In a different study, Zang et al.11 hypothesized that mitochondrial metabolic responses fail with extended wakefulness, and neuronal injury consequently occurs. In this study, mice lacking the SIRT3 gene (i.e., SIRT3 knockout mice) and wild-type mice (i.e., mice that had the SIRT3 gene) were subjected to extended wakefulness. On examining their brains, Zhang found a greater loss of locus ceruleus neurons in the knockout mice.

Based on these findings, Zhu concluded that wake-induced mitochondrial stress within the locus ceruleus neurons reduces SIRT3 activity, which ultimately leads to the degeneration of the locus ceruleus neurons.

Deepti Nair et al.12 demonstrated that excessive NADPH oxidase activity may be involved in central nervous system dysfunction induced by intermittent hypoxia. They exposed wild-type mice and NADPH knockout mice to intermittent hypoxia in a model of OSA. The animals’ respective control groups were exposed to room air. After intermittent hypoxia exposure, the wild-type mice had significantly higher levels of NADPH oxidase expression and activity in tissues derived from the cortex and hippocampus,

REFERENCES

1. Sukhal S, Khalid M, Tulaimat A. Effect of wakefulness-promoting agents on sleepiness in patients with sleep apnea treated with CPAP: A meta-analysis. Journal of Clinical Sleep Medicine. 2015;11:1179-1186.

2. Gasa M, Tamisier R, Launois SH, et al.; Scientific Council of the Sleep Registry of the French Federation of Pneumology. Residual sleepiness in sleep apnea patients treated by continuous positive airway pressure. Journal of Sleep Research. 2013;22:389-397.

3. Pepin JL, Viot-Blanc V, Escourrou P, et al. Prevalence of residual excessive sleepiness in CPAP-treated sleep apnoea patients: The French multicentre study. European Respiratory Journal. 2009;33:1062-1067.

4. Alchanatis M, Deligiorgis N, Zias N, et al. Frontal brain lobe impairment in obstructive sleep apnoea: A proton MR spectroscopy study. European Respiratory Journal.

2004;24:980-986.

5. Morrell MJ, McRobbie DW, Quest RA, et al. Changes in brain morphology associated with obstructive sleep apnea.

Sleep Medicine. 2003;4:451-454.

A2 Zzz 26.1 | March 2017

11 6. Macey PM, Henderson LA, Macey KE, et al. Brain morphology associated with obstructive sleep apnea.

American Journal of Respiratory and Critical Care Medicine.

2002;166:1382-1387.

7. Antczak J, Popp R, Hajak G, et al. Positron emission tomography findings in obstructive sleep apnea patients with residual sleepiness treated with continuous positive airway pressure. Journal of Physiology and Pharmacology.

2007;58(Suppl 5 Pt 1):25-35.

8. Zhu Y, Fenik P, Zhan G, et al. Degeneration in arousal neurons in chronic sleep disruption modeling sleep apnea.

Frontiers in Neurology. 2015;6:109.

10. Zhu Y, Fenik P, Zhan G, et al. Selective loss of catecholaminergic wake active neurons in a murine sleep apnea model. Journal of Neuroscience. 2007;27:10060-10071.

11. Zhang J, Zhu Y, Zhan G, et al. Extended wakefulness: Compromised metabolics in and degeneration of locus ceruleus neurons. Journal of Neuroscience. 2014;34:4418-4431.

12. Nair D, Dayyat EA, Zhang SX, et al. Intermittent hypoxia-induced cognitive deficits are mediated by NADPH oxidase activity in a murine model of sleep apnea.

PLoS One. 2011;6:e19847. 

9. Xiong Y, Zhou XJ, Nisi RA, et al. Brain white matter changes in CPAP-treated obstructive sleep apnea patients with residual sleepiness. Journal of Magnetic Resonamce Imaging. 2016 doi: 10.1002/jmri.25463.

20%

Discount on registration to those who register for the AAST Spring Course and the FOCUS conference.

Join AAST for our spring course in Orlando, Florida - Thursday May 4, and Sunday May 7, 2017 during the FOCUS Conference. Sleep Center Essentials Course: Are You Up to Date and Safe to Practice?

On May 4, the 8 hour, 8 CRCE and/or 8 CEC course is designed for you to get a feel for the perspective of both patients and families and an understanding of the impact of quality and safety on staff morale, patient satisfaction and laboratory operations.

There is a 20% discount for those who register for this course and the FOCUS Conference. Consider registering for this informative AAST course, then staying for one or both days of the conference, held at Rosen Shingle Creek Resort in Orlando, Florida.

A2 Zzz 26.1 | March 2017

The AAST will also have a Sunday Morning Course on May 7, 2017 with topics on: » 10-20 Measurements » Instrumentation: Filters & Amplifiers » Procedures in the Sleep Laboratory » Pediatric Considerations in the Lab

To register for this course or conference visit www.foocus.com/AASTWorkshops-landing

EXPLORE NEW CAREER OPPORTUNITIES by browsing through the AAST Job Board!

www.aastweb.org/Jobboard.aspx

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13

FULL-FACE MASKS: A FULL CAN OF WORMS

By Thom Russell, RRT(Adv); PSGT

A

n otherwise healthy 46 year old male (BMI 24.6, neck circumference 40cm) with treated hypertension, and complaints of troublesome snoring was diagnosed by polysomnography (PSG) (details unknown) in the community with “severe” obstructive sleep apnea (OSA). Facial/cranial structure appear normal and without obvious retrognathic quality. The mandibular protrusive range is 6mm + 6 mm from an edge to edge position. Body weight appeared normally distributed and there was no documented upper airway abnormality.

He was treated with interactive (auto) continuous positive airway pressure (CPAP). After briefly trying a conventional nasal interface he claimed to be unable to breathe through his nose.

He was provided a full-face mask and based on the interactive data, converted to 12 cmH2O fixed pressure. He completed the trial however became disgruntled with the CPAP provider and obtained his own 60 series Philips-Respironics AUTO CPAP machine set to fixed pressure of 12 cmH2O from an Internet supplier. He kept the full-face mask he had been fitted with by the home care provider and purchased a variety of interfaces online.

Over the next two years he struggled to use CPAP successfully and ultimately was referred to a Respiratory/Sleep Specialist for investigation of OSA and respiratory symptoms related to his diaphragm and possible hiatal hernia. The patient claimed to become dizzy when breathing through his nose and was deemed a chronic mouth breather. The machine derived residual apnea– hypopnea index (AHI) was considered ‘very high’.

Formal PSG was conducted for the purposes of CPAP titration.

During the PSG the patient’s own full-face mask proved problematic and was switched to a newer oral/nasal hybrid full-face mask, Philips-Respironics AmaraVIEW. Pressures were titrated from 9 to as high as 12 cmH2O with intermittent THOM RUSSELL, RRT(ADV); PSGT

Post PSG the patient was prescribed interactive CPAP (8-16 cmH2O), maximum A-FLEX with an AmaraVIEW full-face mask. After several nights’ adjustment, he continued to struggle with therapy. Both patient and wife were unhappy describing therapy as, “not working at all”.

Given his current therapy was failing and in effort to “rescue” the patient he was brought in for review. Though struggling with CPAP, he demonstrated good adherence using CPAP: more than 90 percent of 31 nights, averaging over 5 hours with refractory machine detected AHI at 19/Hr and the 90th percentile at 13 cmH2O. Despite repeated claims by the patient of being unable to breathe through his nose, no oral breathing was observed while awake in the clinic. His voice did not have a nasal quality. When asked, he was able to voluntarily move air through his nose. Though somewhat restricted, the nasal passages appeared sufficiently patent to support airflow at rest as well as facilitate a reasonably unrestricted ‘sniff maneuver’.

It was thought best to start over, from the beginning and the patient was encouraged to attempt using a simple nasal interface.

While in the clinic, CPAP was reduced to 5 cmH2O and applied to the patient. He was reassured, coached, and coaxed to breathe through his nose. The CPAP was disconnected and reconnected while the patient wore the mask so he could become familiar with the sensation of breathing against air pressure and build confidence.

The nasal interfaces he had collected over the years were reviewed.

All were poor choices and improperly sized. He was fitted with an appropriate nasal interface.

Over the following weeks he got on to therapy well. Contrary to his belief, he discovered he was able to comfortably breathe through his nose. His wife was very pleased with the abolition of snoring and oral leak.

Over the following weeks, adherence with therapy proved excellent at 100 percent averaging near 6 ¼ hours nightly. The

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 Continued on Page 14

Thom Russell, RRT(Adv); PSGT, spent 26 years working at the Royal Jubilee Hospital in Victoria, B.C. Canada as SleepLab Supervisor (Retired December 31, 2015) and 22 years as the owner /operator of Island Sleep Health Services Inc. in Victoria, B.C. Canada (Retired August 31, 2016).

leak, persistent flow limitation and refractory AHI 9 - 11/hr. A positional component was identified. The head of the bed was elevated in order for the patient to tolerate the air pressure though there were complaints of aerophagia.

 Continued from Page 13

14 machine detected AHI at 5 per hr. with the 90th percentile at 7.5 cmH2O. Additionally, the patient considered his abdominal (questionable hernia) difficulties improved.

DISCUSSION:

Full-face masks are obtrusive, and prone to leak. Risk of aerophagia and aspiration is increased, and full-face masks have been reported to be less effective than nasal masks. 1 In terms of CPAP compliance and comfort, comparative studies of CPAP interfaces consistently identify full-face mask limitations. 2-4 Despite the literature, community CPAP providers, physicians, and sleep technologists are sometimes hasty to use full-face interfaces. Reasoning may include: • Patient claims of being unable to breathe through their nose • Prior uvulopalato reduction surgery • Complaints of oral leak with nasal interface • Inability to fit the patient with a conventional nasal interface.

This case illustrates the potential deleterious effect of full-face masks (including late model interfaces) specifically, excessive CPAP pressure requirements. With limited and conflicting reports 5-7 the phenomenon is not clearly understood. One theory is the full-face mask applies posterior pressure against the lower mandible causing retrusive positioning and reduced oropharyngeal patency. 8-9 Identifying patients vulnerable to this problem has yet to be described. It is unknown how such patients may respond to mandibular advancement appliance treatment.

Another potential problem caused by full-face masks (not recognized or studied) is a “draft effect” caused by the placement of the vent. Most modern full-face masks integrate the vent into the mask itself, directly adjacent to the patient’s nose. Continual airflow through the vent causes excessive drying and irritation of the nose and sinuses, despite supplemental heated humidity.

In conclusion, though full-face masks are warranted in select cases, technologists and physicians should be aware of potential difficulties and be prepared to re-evaluate patients experiencing difficulty.

AC. A randomized controlled trial on the effect of mask choice on residual respiratory events with continuous positive airway pressure treatment. DOI: http://www. sleep-journal.com/article/S1389-9457(14)00049-5/abstract 2. Mortimore IL, Whittle AT, Douglas NJ. Comparison of nose and face mask CPAP therapy for sleep apnoea. Thorax. 1998; 53: 290-292.

3. Borel JC, Tamisier R, Dias-Domingos S, Sapene M, Martin F, Stach B, Grillet Y. Type of mask may impact on continuous positive airway pressure adherence in apneic patients. PLoS One. 2013; 8: e64382.

4. Teo M, Amis T, Lee S, Falland K, Lambert S, Wheatley J. Equivalence of nasal and oronasal masks during initial CPAP titration for obstructive sleep apnea syndrome.

Sleep. 2011; 34: 951-955.

5. Bakker JP, Neill AM, Campbell AJ. Nasal versus oronasal continuous positive airway pressure masks for obstructive sleep apnea: A pilot investigation of pressure requirement, residual disease, and leak. Sleep Breath. 2012;16(3):709-16.

6. Ng JR, Aiyappan V, Mercer J, Catcheside PG, Chai-Coetzer CL, McEvoy RD, Antic N. Choosing an oronasal mask to deliver continuous positive airway pressure may cause more upper airway obstruction or lead to higher continuous positive airway pressure requirements than a nasal mask in some patients: A case series. J Clin Sleep Med. 2016 Jun 9. [Epub ahead of print] 7. Bettinzoli M, Taranto-Montemurro L, Messineo L, Corda L, Redolfi S, Ferliga M, Tantucci C, et al. Oronasal masks require higher levels of positive airway pressure than nasal masks to treat obstructive sleep apnea. Sleep Breath Schlaf Atm. 2014; 18: 845-849.

8. Schorr F, Genta PR, Gregório MG, Danzi-Soares NJ, Lorenzi-Filho G. Continuous positive airway pressure delivered by oronasal mask may not be effective for obstructive sleep apnoea. European Respiratory Journal 2012 40: 503-505.

9. Kaminska M, Montpetit A, Mathieu A, Jobin V, Morisson F, Mayer P. Higher effective oronasal versus nasal continuous positive airway pressure in obstructive sleep apnea: Effect of mandibular stabilization Can Respir J. 2014; 21(4): 234–238. 

REFERENCES: 1. Ebben MR, Narizhnaya M, Segal AZ, Barone D, Krieger

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EDUCATING ABOUT “ORDERLY SLEEP” IS AS IMPORTANT AS EDUCATING ABOUT SLEEP DISORDERS

By Brendan Duffy, RST, RPSGT

W

ho really is their opponent when they claim to be a seriously committed athlete? Is it actually themselves, due to a lack of knowledge about sleep? How do you truly impact a life of an “on the go” financial guru? Do you assume they know about lightboxes and time zone adjustments? Why are we too often silent about the damage being done to our youth due to early start times at schools across the country?

I recently returned from the Board of Registered Polysomnographic Technologists (BRPT) Symposium in Atlanta where I presented the need to spend as much time working with athletes (and everyday corporate employees too) about what I call “orderly sleep”, as we do discussing “sleep disorders.” As sleep educators, we too often focus on continuous positive airway pressure therapy (CPAP) compliance and usage, insomnia, and other sleep disorders, while we miss the low hanging fruit which is discussing, coaching, and educating patients and clients about basic sleep hygiene. This important education is sorely lacking in schools, job sites, and even in many hospitals.

The American Academy of Pediatrics (AAP) cited a major problem with the currently available commercial sleep coaches as being ill prepared in many instances. Many of these so called coaches obtain credentials by sending a check to an online company and passing online courses. They then hand out business cards that state they are sleep coaches. As a matter of fact, the AAP in 2015 stated that over half of these coaches (54 percent) had neither the proper education nor healthcare experience. Additionally, 44 percent did not report any secondary education. Yet they prosper because of the many people requesting help verses the few truly qualified and certified educators that are available. We need to look in the mirror and realize we have not done a good job of creating sleep hygiene awareness. We are the true professionals that can differentiate when we can help, and when we need to refer the patient to see a sleep specialist MD. All the lavender oil and tart cherry juice in the world will not help a patient with periodic limb movements of sleep BRENDAN DUFFY, RST, RPSGT Brendan Duffy, RST, RPSGT is the Coordinator/Manager of a six bed AASM accredited sleep disorders center at St. Charles Hospital in Port Jefferson, N.Y. With almost 20 years of sleep medicine experience, he enjoys speaking and writing on various sleep topics especially sleep as it relates to athletic competition and performance.

(PLMS), and many of these high priced online certified coaches probably don’t know what PLMS even is!

As a registered sleep technologist and a sleep educator, have you ever gone to your local fitness center or gym and asked about initiating a sleep program? Have you gone to a local trucking company and asked if they need assistance to review their shift schedules? Do you think they might listen if they could save money on injuries, errors, and accidents? Have you ever thought about producing sleep hygiene videos for local corporate customers to share with their employees? Have you offered to write articles about sleep issues for your local community or church newsletters?

We have to explain to our community members that it is neither “macho” nor healthy to “work until you drop”. We have to counsel bankers and investment staff that do not know how to properly prepare for long overseas trips and the time zone changes they must overcome. We have to help them prepare days in advance so they are on top of their game when they arrive at their destination.

We need to coach high school and college athletes that they run the risk of a concussion, or a subsequent concussion if they are sleep deprived. For instance, we need to make young basketball athletes understand that their cell phone use at night can do more to sabotage their game performance than many of their opponents. We need to explain to coaches about teenage circadian rhythms. Sleep deprivation can cause a mental state that causes turnovers, inability to react to opportunities, and causes the same results as any hulking opponent that rejects your easy layups!

We need to work with local schools to help parents and children find more time for sleep in their daily lives. It has been stated by others that in life we are bound to live in pain…the pain of discipline or the pain of failing to adhere to this discipline and thus not becoming as good as we can be. We have choices to make and one of them that often is misplayed is not taking your sleep as seriously as you do your diet, exercise, and playbook preparations.

As sleep educators, I ask you to start thinking outside the box. I ask you to look around for opportunities OUTSIDE the sleep lab. Work with athletes, work with companies, write articles and blogs, and help your local public service employees develop a healthy shiftworlk lifestyle. Because in the end, the community members with “disorderly sleep” can become as impaired, injured, and unhealthy as the patients you routinely assist that have “sleep disorders”!

Sleep Well. Compete Better! 

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COMPARISON OF CPAP VERSUS APAP

By Krystle Minkoff, RPSGT, RST

A

s we delve into the specifics of PAP (positive airway pressure) treatments for obstructive sleep apnea (OSA), this article begs to relay the differences in efficacy of continuous positive airway pressure (CPAP) vs. automatic positive airway pressure (APAP).

APAP can be set to a straight CPAP mode. CPAP devices on the other hand are unable to be adjusted to have varying pressure settings.

APAP machines may be better suited for those that toss and turn during the night. Due to gravity, supine sleepers or patients in rapid eye movement (REM) generally have the highest number of We shall begin with a review of obstructive sleep apnea. respiratory events vs. being lateral or prone. This allows the APAP to Obstructive sleep apnea is a condition in which an obstruction to automatically adjust the pressure upward when more severe events are the flow of air (and oxygen) occurs during sleep, resulting in poor detected and lower the pressure accordingly when positional changes nighttime sleep and consequent daytime sleepiness. When sleep apnea is uncontrolled, it may contribute to elevated blood pressure, that reduce event occurrence are apparent. and an increased risk of stroke and heart attack. The treatment of CPAP also machines do not allow for physical changes, such as choice for OSA has primarily and historically been CPAP, which weight loss. It is recommended that following a 10 percent increase or is the only 100 percent effective therapy for treatment of OSA. decrease in body weight the CPAP patient should undergo another evaluation to determine if a pressure increase or decrease is warranted.

We shall now investigate the differences, pros & cons, and APAP devices can help eliminate the need for additional expensive efficacy of treatment between CPAP and APAP therapy. CPAP devices are titrated to a single set pressure by a sleep technologist. in-lab sleep testing.

The titration study is generally conducted after a traditional in-lab polysomnogram for diagnosis of OSA and is intended Those who are diagnosed using a home sleep apnea test (HSAT) will to determine the CPAP pressure setting needed to alleviate or often be prescribed an APAP device. This is because a HSAT cannot eliminate the majority, if not all, respiratory events occurring determine stages of sleep and as previously discussed, CPAP devices during the night. are calibrated for breathing needs when events are at their worst (supine or during REM sleep). HSAT evaluate respiratory events that Contrary to the delivery of a single set pressure, APAP machines have occur through the course of the night, which may include wake time. a complex algorithm that detects on a breath-by-breath basis what APAP can be used to determine the range of CPAP needed over the pressure the patient needs at that moment and adjusts accordingly night and that range can later be fine-tuned using remote monitoring. when respiratory events occur (or do not occur). In essence, the APAP device finds the ideal pressure for any given moment.

There are pros and cons to both therapies – the technologist needs to be aware of these to assess the efficacy of patient therapy for It could be argued that one of the “cons” of CPAP is that a single various types of patients set pressure may be cumbersome to tolerate (especially at higher settings), and this therapy does not adjust to varying pressure needs APAP therapy is swiftly becoming the go-to machine for treating throughout the night. More and more frequently APAP devices are OSA as the technology becomes better developed. However, there being prescribed in lieu of CPAP devices because of their versatility are some instances where a CPAP device may be the better choice: and ability to adapt to patient needs over the course of the night.

• This may make it difficult for some physicians to determine the best machine for their patients.

While APAP machines are costlier, APAP devices can also be set to a • Changes in pressure settings can be slow to react to ideal single pressure. If for some reason APAP therapy is not working well pressure needs. for the patient, they would not need to get a different machine because • APAP machines are not ideal for patients who, once starting treatment, are discovered to have central sleep apnea; in which case an adaptive servo ventilation (ASV) or bilevel positive KRYSLE MINKOFF, RPSGT, RST airway pressure (BiPAP) machine may be the better choice.

Krystle Minkoff, RPSGT, RST, is a veteran sleep expert with more than 15 years of experience, who brings vast knowledge and authority as a consultant and published author to the sleep industry. Krystle shares her experience by continually producing new industry related articles.

• APAP machines are not recommended for patients with certain comorbidities. These include conditions such as chronic heart failure or obesity hypoventilation syndrome.

• While APAP therapy fluctuates between high and low pressure settings; the range of settings may need to be fine-tuned over time. 

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17

IF THE EYES HAVE IT, YOU MAY HAVE IT … OSA THAT IS!

By Brendan Duffy, RST, RPSGT

R

ecently I have written some short blogs on the AAST website on some interesting eye related obstructive sleep apnea (OSA) related conditions.

It sparked my interest to take a… (pardon the pun) ‘longer look’ at some of the things an ophthalmologist might discover during an eye test that can signal the need for sleep screening. With sleep apnea going undiagnosed to such a large degree, the ability for our allies in other health fields to become familiar with, and educate the patient about, sleep issues and the dangers of untreated sleep apnea is a great benefit for patients who need to be tested and treated.

A few of the visual conditions that should be noted and addressed by an ophthalmologist represent an opportunity for sleep professionals and sleep educators to bolster awareness of sleep apnea within the community of ophthalmologists and optometrists. The eye related conditions that could be discussed include a number of conditions commonly seen during an eye examination.

cannot be restored in that eye, treating the patient’s sleep apnea may prevent this condition from occurring in the other eye. The incidence of the involvement of the second eye is said to be about 15 to 18 percent of the cases of NAION. Glaucoma: Glaucoma causes damage to the optic nerve from fluid buildup that causes pressure in the eye. According to new research, from Taipei Medical University, patients with glaucoma are almost 13 percent more likely to have OSA. Those that were diagnosed with OSA were 1.67 times more likely to have open-angle glaucoma in the five years after their diagnosis as compared to those without OSA. Retinal Vein Occlusion (RVO): This is one of the most common causes of vision loss in the world. While not as common as diabetic retinopathy, it is a fairly common condition and the links to OSA indicate that OSA is more prevalent in patients with RVO. The eye damage causes a severe dysfunction of the autoregulation of three major blood vessels. It is thought that the mechanism for this damage is the frequent incidents of OSA related hypoxia. In one fairly recent Oxford study, a high prevalence of apnea was found in patients with diabetic clinically significant macular edema (CSME). As we see with other hypoxia manifestations, the assault to the retina from decreased oxygen can increase the damage that is already occurring in cases of diabetic retinopathy and hypertensive retinopathy. This hypertensive condition may actually be due to the associated blood pressure spikes that occur during each apneic event.

Floppy Eyelid Syndrome: Dr. Deepak Grover of the Cincinnati Eye Institute says that this condition is the number one reason that he refers patients for a sleep study. The eyelids of patients with FES are loose and rubbery and are easily everted in sleep. The eyelid can easily turn either inward or outward and patients with this condition usually complain about other symptoms such as irritation, dryness, grittiness, redness, or discharge, and can be stressed by pressure from a pillow or other bedding. They also can experience keratitis, or conjunctivitis. According to an online article in Optometry Times, fewer than 5 percent of those that have OSA have FES, but approximately Papilledema: This condition is linked to idiopathic intracranial hypertension. It occurs most frequently in young woman and is also 100 percent of those with FES have OSA! known as optic disc swelling. An increase in CO2 concentration as NAION: Nonarteritic anterior ischemic optic neuropathy is is seen in OSA patients may result in dilation of the blood vessels another strong reason to refer for sleep testing. Dr. Grover and an increase in pressure which leads to the aforementioned optic indicates that up to 80 percent of patients with NAION have disc swelling. Evaluation and treatment of sleep apnea can improve been found to be positive for OSA. Basically, this condition is due a patient’s vision and papilledema within a matter of weeks! to a loss of blood flow to the optic nerve that results in vision loss in one eye. The condition is painless and although the eyesight Many of these problems can be spotted by an ophthalmologist during a dilated retinal exam. If they are aware of the effects of sleep apnea, they may be in position to save a person’s sight.

BRENDAN DUFFY, RST, RPSGT We have a part in making sure our community of allied health Brendan Duffy, RST, RPSGT is the partners are aware of these types of disease connections. We must Coordinator/Manager of a six bed AASM educate others to look for, and be on guard for, sleep disorders accredited sleep disorders center at St. among their patients. Recognizing them will many times solve a Charles Hospital in Port Jefferson, N.Y. multitude of the patient’s medical issues. If the patient is sent for With almost 20 years of sleep medicine experience, he enjoys speaking and writing sleep testing and is treated appropriately, the eye doctor may have on various sleep topics especially sleep also saved their life. Or, at the least, improved the quality of their as it relates to athletic competition and days and nights. And that would be a pleasant sight for all of us in performance. the fields of sleep medicine and ophthalmology. 

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REFERENCES

1. 5 Eye Issues and Sleep Disorders: The Ocular Signs of Sleep Apnea- Laci Michaud 2/2/16 http://www.alaskasleep. com/blog/5-eye-issues-and-sleep-disorders-the-ocular-component-of-sleep-apnea 2. Stuart A. Obstructive Sleep Apnea and the Eye: The Ophthalmologist’s Role. EyeNet; 2013(2):33-35 Available from: https://www.aao.org/eyenet/article/obstructive-sleep-apnea-eye-ophthalmologist-s-role. 

2017 SLEEP SUPPLIES CATALOG

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Nominate them for an AAST Award:

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For more information and to nominate, visit: aastweb.org/awards.aspx A2 Zzz 26.1 | March 2017

19

THE NEW SLEEP GADGETS: WHAT TECHNOLOGISTS NEED TO KNOW

By Tamara Sellman, RPSGT, CCSH

T

he personal sleep technology marketplace came of age at the Consumer Electronics Show (CES) in Las Vegas last January when the event introduced an entire wing of personal sleep technology products as part of an effort launched in partnership with the National Sleep Foundation.

Functions: To track sleep quality and quantity, to measure and record movement, to check heart rate, to capture respiratory rates and patterns, to measure brain signals, to deliver relaxation, to note changes in body temperature, to elicit wakefulness in the morning.

As sleep technologists, it’s important that we have a firm grasp on Sleep Tracking Apps what these new DIY healthcare tools can do (or can’t do) to help a Smartphone-synched apps, which may or may not incorporate wearables or other technology. patient with their sleep problems. Why? By now you’ve likely encountered some sort of do-it-yourself sleep tracking app, either through a friend, a family member, or a patient. You may have even adopted the use of one or more of these devices yourself.

Functions: To track anything from sleep apnea to insomnia to sleep quality/quantity to REM cycles to snoring to whole family sleep habits.

So what exactly is this new branch of sleep technology?

Functions: Many of the same functions as wearables.

DIY SLEEP TECHNOLOGY CATEGORIES

Light Technology This includes both light fixtures and light-blocking technologies.

Embedded Technology Objects that include sensors and trackers that are not worn, such Patients may (and do) turn to these options first before considering a trip to their primary care doctor because they’re easy as smart mattress pads and smart pillows, and which may or may not incorporate sleep tracking apps. to access, affordable, and aesthetically alluring.

is currently writing a book on sleep hygiene for mainstream audiences which she hopes to launch in 2017. She is a web consultant for the American Sleep Apnea Association and curates the sleep health information clearinghouse, SleepyHeadCENTRAL.

Functions: To provide guidance for first-time or struggling CPAP users, to encourage compliance to therapies, to help insomniacs by way of CBT-i applications.

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 Continued on Page 20

Among ordinary users, this technology is called “personal sleep technology,” “consumer sleep technology,” “home sleep technology,” or just “sleep technology.” It might be more accurately Functions: To improve melatonin production in the early evening, to awaken the user, or to improve alertness in the morning once awake. called “do-it-yourself sleep technology” to differentiate it from technology found in the sleep center.

Sound Technology This DIY sleep technology breaks out into the following categories: Often also wearable, but includes any technology using noise or music to encourage sleep onset.

Wearables These devices are worn and may or may not include the use of a Functions: To encourage relaxation and sleep onset, and to block sleep tracking app. Iterations include bracelets, necklace pendants, noise in the sleep environment (externally, such as traffic, or rings, watches, sleeves, personal pulse oximeters, masks, earbuds, internally, such as people talking in the next room). headbands, headphones, forehead pads, eyewear, pajamas, and waist/chest belts.

Interactive Technology Technology that incorporates a therapeutic management team, which can be comprised of a live consultant, a hosted 24-7 TAMARA KAYE SELLMAN, RPSGT, CCSH website, a text or email communication arrangement with a sleep specialist, or other direct access to a coach, therapist, educator, or Tamara Kaye Sellman RPSGT, CCSH, is a other professional. science journalist and sleep health activist. She

 Continued from Page 19

20 Miscellaneous Technology WHY PEOPLE CHOOSE DIY SLEEP Specific technologies meant for specific populations (i.e. babies, TECHNOLOGY schoolchildren, pets, drivers, CPAP users, those with hypersomnia, They have heard that sleep matters. fatigued employees).

This is a positive! It means they are paying more attention to their sleep health. They choose it as a way to get some insight into Functions: Anything from monitoring infant breathing to smart their sleep patterns, often to determine whether they need to get alarm clocks to drowsy driving prevention gadgets to apnea additional help. detection sensors and nap pods.

Friends, family members, colleagues, and influencers advocate it.

Combinations of all of the above…

Word of mouth is powerful. Many use it as a first-line approach Innovative combinations of these different technologies arise for addressing insomnia or daytime sleepiness. when manufacturers and developers find ways to distinguish their products from the rest of the competition by combining functions. It comes with their fitness technology, so why not track sleep as well?

Some people love to collect data and follow statistics (baseball BUT DOES DIY SLEEP TECHNOLOGY WORK? fans!). Sleep tracking can become a hobby as well as a habit.

Some of it does, some of it doesn’t. Some of the functions aren’t Meanwhile, wearables have become a fashion trend. particularly useful for the end user. Collecting data is only useful if it can be applied in a way that solves a problem.

They know they have problems but resist seeing a sleep specialist.

How they can work is a different matter. As sleep technologists, we know how the technology should work. These products mirror the basic functions of the tools we already use, such as actigraphy, oximetry, plethysmography, vital sign collection, even basic EEG and EOG. The challenge, however, lies in the value of the end result.

How accurate is the technology? DIY sleep technology can vary widely in what it purports to do; accuracy is an ongoing challenge for developers.

Are the sensors collecting enough data to be useful? These are not the high-quality lab tools we use; if they were, consumers would be outpriced. These instruments also don’t capture the full picture of sleep like an overnight polysomnogram can: Imagine running a diagnostic test without EEG, for instance.

Do users apply this technology properly? It’s hard to say. These tools require patient education to work; developers design them for the lowest common denominator to use.

Why? Because they have inadequate insurance coverage; they fear medical procedures; they don’t trust doctors; they don’t see sleep as critical to wellness; they believe they’ll only be given drugs or a “breathing machine.”

HOW SLEEP TECHNOLOGISTS CAN STAY ON TOP OF THIS TREND

Learn everything you can about these technologies.

You could start with the list of categories above and spend an hour a week doing research on each until you get a feel for what these technologies claim.

Try printing out reviews from tech websites or watching how-to videos from manufacturers. A simple search in eBay or Amazon can highlight claims and technical specifications.

Another reason to attend sleep conferences and technology conventions in person: there are booths displaying these products, with representatives to address questions about functionality, purpose, and accuracy. You can also take their brochures to refer to later.

Do users know how to interpret the results? Some kinds of data seem easy to interpret (i.e. physical movement) but in the context of other data that isn’t being recorded (such as brainwave activity to distinguish sleep from wake), how useful is that data?

When patients bring them in, ask them how they use them.

During your patient encounter process, take some notes (brand, model) and find out what inspired the patient to choose that particular gadget. That can tell you a lot about their motivations for getting help. Listening without judgment works well in this case.

Also, users tend to focus on numbers without appreciating that there is a range of what is considered normal. They can misinterpret the most accurate data as either positive or negative when, in fact, the reality could be quite the opposite.

Be prepared to discuss product functions with patients.

Once you do the research, you’ll see how the engineering behind these gadgets mirrors what you are doing in the sleep center.

If a patient shares their use of a product, you can help them to better understand how it works by comparing it to the multiple

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21 technologies built into a polysomnogram and explain why the in-lab sleep study remains the “gold standard” for sleep diagnostics.

Be prepared: If a patient visits a sleep clinic for a consultation and testing, he may use gadget data as grounds to “prove” a self diagnosis or disprove the sleep doctor’s diagnosis.

AN APP THAT FOSTERS SLEEP RESEARCH One of the ways in which DIY sleep technology can have a lasting and helpful impact on sleep health is through its ability to collect and analyze data. Who needs data more than sleep patients, but sleep researchers?

Be wary of impedances issues and potential interference.

If patients want to use these gadgets in the sleep center, you’ll need to first confirm that they won’t compromise the quality of your sleep study.

The free SleepHealth App and Mobile Study download (iOS

Most patients will understand after the hookup that they are using sleep technology “on steroids” when compared to their little gadget and probably won’t demand using their own, but if they do, be prepared to explain why interference is a no-no.

citizen researcher, get support, give us your insights and help

Don’t discount their use of these products.

only, with Android launching later this year) records data from its users in a vault for researchers to access.

The premise behind this effort is multifaceted: “Become a us to direct future research.”

The app, powered by IBM Watson and launched in March 2016, is the product of a new patient-led effort led by the American Sleep Apnea Association (ASAA) in concert

We all know sleep patients are pretty defensive about a lot of things (snoring, for starters). We can’t stop patients from using these devices, but we can listen to their stories. While this technology may or may not help them, it’s the intent behind their usage that matters most.

Patients who go this route are seeking information to solve a problem.

By using these products, they could become better educated about sleep. Informed patients are empowered patients, more likely to stick to a therapy than those who don’t care about their sleep health.

THE BRIGHT SIDE

Sleep is “the new black”.

People who use DIY sleep technology are being proactive and should be acknowledged for their self advocacy. They also shine a spotlight on the value of sleep when they do so. This has been a huge public health roadblock up until now. Awareness matters, however it occurs.

Technology before drugs.

These users also use these tools because they want nonpharmaceutical solutions, which is a healthy trend away from previous drug-seeking behaviors.

This is not to say that gadgets can or should replace medications for some patients.

with sleep researchers led by principle investigator Carl Stepnowsky PhD, Associate Adjunct Professor at the University of California, San Diego.

The SleepHealthApp is more than a tracker. It’s an actual mobile research study (Protocol No. 20150142) which investigates connections between the user’s sleep and general health, medical conditions, daytime alertness, and productivity.

This technology uses the iPhone and/or the Apple Watch to advance clinical research on sleep and sleep disorders with relation to other medical conditions. You can already guess at what some of these are: diabetes, COPD, and heart disease, for starters.

The app also personalizes insights into the user’s sleep habits and general health and well-being. But, more importantly, this app is a patient-led research study that allows participants to be equal partners in the monitoring and management of their symptoms.

Anyone age 18 or over can use the app; it does not limit participants by gender, health status, or any other demographic. Currently the app has only an English language version, but the ASAA plans to generate it in other languages in the future.

However, in light of the current opioid epidemic, habituation to zolpidem, and black market for “performance drugs” like modafinil, the pivot toward technology and away from unnecessary medications should be considered positive.

 Continued on Page 22 A2 Zzz 26.1 | March 2017

 Continued on Page 22

 Continued from Page 21

22 A way in for CBT-i.

The rise of Cognitive Behavioral Therapy for insomnia (CBT-i) can be better supported by the interactive features of personal sleep technology.

Apps, wearables, and embedded gadgetry can work together as part of a sleep health program for insomniacs who cannot get the therapy they need where they live.

There’s a shortage of professionals who can provide CBT-i, which research shows can be effective for treating multiple types of sleep disorders. Digitized options combining one-on-one support with technology and telemedicine may solve this supply-and-demand problem.

We’re only at the beginning.

Finally, the new sleep technology may be limited in its functionality, accuracy, and usefulness for now, but all new technology begins with glitches and bugs.

As more people use it, the best products in terms of engineering and design will succeed, while the least effective technologies will fail. And, more feedback from users means more chances to refine and perfect these devices.

Final analysis, relevant to sleep clinics: Whether this technology becomes so good that it replaces the actual work of an RPSGT is up for debate, but suffice it to say, it does us no good as sleep technologists to ignore these tools: they are not going away any time soon. 

 Continued from Page 21 Principle investigator Dr. Stepnowsky reports that in the first nine months, 18,000 people downloaded the app and 9,500 consented to participate in the study. Interestingly, he points out that two thirds of users are first-time research study participants.

The app is designed to be easy to use: After download, you register an account (free), learn about the study, review consent information, complete some health surveys, and perform very simple daily tasks (up to 20 minutes of tasks a week); meanwhile, the app collects your data for research purposes.

Its developers see a wide range of longitudinal research opportunities for using it in the future. Envision the Wisconsin Sleep Cohort, which took decades of clerical and research labor to complete. Using today’s data collection technology apps, we can now employ Big Data to work for us in ways which could be a boon for researchers seeking solutions for our most pressing sleep health problems.

Sleep technologists are highly encouraged to download the app and participate in the study.

To learn more visit: https://sleephealth.org/sleephealthapp/

“Final analysis, relevant to sleep clinics: Whether this

technology becomes so good that it replaces the actual work of

an RPSGT is up for debate, but suffice it to say, it does us no good as sleep technologists to ignore these tools: they are not going away anytime soon.”

A2 Zzz 26.1 | March 2017

23

In the Moonlight In the Moonlight: Q&A with Rui de Sousa, 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 Rui de Sousa, RPSGT RST, to complete the following statements. de Sousa has been in the sleep field since 1993. He is a polysomnographer, at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada.

When I was young I wanted to grow up to be…Hockey player, then a fireman, then an astronaut. In that order, all by the time I was in first grade.

I decided to become a sleep technologist because…that’s a long story. Very few people know it. I was at the University of Toronto and making my way towards grad school in psychology, when my Dad got sick in my third year. Grad school was put on hold and meanwhile we scraped along until I got my BSc. The job board listed “sleep tech needed.” I thought it would be a great place to work and continue studying toward the eventual and inevitable grad school. Little did I know how much I would love the field. I never left.

I got my first job in sleep technology at…The Sleep Clinic Scarborough Neurodiagnostic Services. I got quite the education there. I do have to stop and thank Dr. H. Gill for his wonderful mentorship during my time there.

I became an AAST member because…I was a newly anointed RPSGT and felt like I now belonged with the big boys.

The person who has had the greatest influence on my career is…

Dr. H. Gill. His time, patience and friendship are always appreciated.

The most challenging part of my profession is…remaining calm and patient when sleep deprived.

The thing I like most about my profession is…first and foremost, it is the practitioner-patient connection.

The immediate and visceral feedback and gratitude I get from patients, usually suffering from severe OSA, after their first night on CPAP therapy. Secondly, is the camaraderie between all sleep techs everywhere, who suffer through long hours at night, often working alone, that

form a quirky group of professionals, and no matter who they are or where they work, only they would understand the frustration of a bathroom call two minutes after lights out.

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

For fun on days off from work I like to…I am addicted to English Football Saturday and Sunday mornings. Glory Glory Man United!

My favorite TV show is…Star Trek. Sci-fi in general always gets my attention. I am also a fan of the new breed of comic book franchises on the small screen, from Arrow, to The Flash, to Gotham, from Agents of S.H.I.E.L.D., to Daredevil, to Luke Cage to Lucifer. Ok... I know... I lost you at “Star Trek.”

My favorite singer or musical group is…Nickelback!!!! Seriously though, I am a big fan of 80’s-90’s English, New York and Canadian punk/indie music. From Joy Division / New Order, U2, the Ramones, to Skinny Puppy and Ministry. I think I can safely say Jesus and Mary Chain are to blame for my early onset hearing loss!

The website I visit most often is…Ok ... busted ... Facebook.

Yahoo is a close second.

The person I would most like to meet is…Brendan Duffy for putting me up to this! In all seriousness, all politics aside, I would love to meet your President Obama one day. As a non-American, looking through different, international, media filters, looking at how he has handled all the challenges during his presidency; I know I could spend many hours talking to this man.

The biggest change I have seen in the profession since I started is…going from analogue to digital.

Words of advice I have for people who are new to the profession are…sleep. We teach the importance of sleep but often forget to follow that advice.

My professional goals for the next five years are…Win the lottery and spend out the rest of my days on the beach. No? Ok, tour the country attending and lecturing at various conferences.

Get my CCSH too.

Sleep is…for the weak. Ok, ok ... Sleep is what keeps me sane.

A2 Zzz 26.1 | March 2017

24

CERTIFICATION UPDATE: FROM THE BOARD OF REGISTERED POLYSOMNOGRAPHIC TECHNOLOGISTS

By James H. Magruder, BRPT Executive Director

The BRPT Names Jessica Schmidt President-Elect of the Board of Directors The Board of Registered Polysomnographic Technologists (BRPT) named Jessica Schmidt, MA, RPSGT, President-Elect of the Board of Directors. Her two-year term as President will begin in January 2018.

Schmidt has been a member of the BRPT Board since 2014 serving as Treasurer and chair of the Legislative Committee.

Schmidt is currently a Senior Administrator at MedStar Georgetown University Hospital in Washington, DC, where she oversees pulmonary, critical care, sleep medicine, and cardiac procedures.

College in McKinney, TX. Amber was instrumental in the development of the program and building it from the ground up. Prior to joining Collin College, she worked as an RPSGT for the Cleveland Clinic in Cleveland, OH. Amber has spoken at numerous sleep and respiratory care conferences at both the national and state level, including the BRPT Symposium, and has previously volunteered for the BRPT Education Task Force Committee. She is passionate about educating students and the public about the importance of sleep. Prior to her career in sleep, Amber was a child prodigy who started college at 14. After earning her Bachelor of Arts degree at 19, she began her post-collegiate career in the music industry in Nashville, where she worked for eight years, including appearances on American Idol and as an extra in film and TV projects with some of the biggest names in music.

“Jessica has been an extremely effective member of the sleep community for more than a decade,” said BRPT President Daniel Lane, BS, RPSGT, CCSH. “She was director of the first CAAHEP-accredited Polysomnography program in the Mid-Atlantic, she continues to serve on the advisory board of two CoA-PSG programs, and is a founding member and PastPresident of the Maryland Sleep Society.”

Rachel Mouton, RPSGT, CCSH, LPN, Director Rachel Mouton has been working in the sleep field for more than 15 years. She entered the field of sleep medicine through nursing and is currently the clinical director of Sleep Solutions of New Iberia in Louisiana, a 6-bed sleep center. For the past eight years, Rachel has worked with the BRPT’s Exam Development Committee on exam development as well as assisting with the Job Task Analysis and standard setting. Rachel is a strong promoter of continuing education within the sleep community and has an active community sleep education program through which she leads the training of sleep technologists and works with physicians entering the field. Rachel also serves on the board of directors of the Louisiana Academy of Sleep Medicine. In addition, she has published articles in A2Zzz magazine.

“I’m thrilled to serve as BRPT’s next President, following a long line of passionate and committed sleep professionals who’ve worked hard to elevate our profession,” said Jessica Schmidt, MA, RPSGT. “I’m particularly proud of my work around the CCSH credential – writing the CCSH Reimbursement Guide and co-editing the CCSH Study Guide were extremely rewarding.

As all of our roles in the community evolve, I look forward to continuing to work hard and advocate on behalf of the sleep profession and the patients we serve.”

Additionally, Steve Marquis will begin his term as treasurer and two new board members were elected.

NEW BOARD MEMBERS

Amber Allen, BA, RPSGT, RST, Director Amber Allen has been in the sleep field for eight years and currently serves as the Program Coordinator to the CAAHEPaccredited Polysomnographic Technology Program at Collin

Biographies of all BRPT Board members can be found at www.brpt.org.

The BRPT Board of Directors is comprised of volunteer members, all of whom serve four-year terms. The Board is international in scope and blends the expertise of the sleep community representing the interests of the consumer, patients, educators, and sleep technologists. 

A2 Zzz 26.1 | March 2017