1) The document discusses guidelines for comprehensive sleep therapy, including positive airway pressure being the primary treatment for mild, moderate, and severe obstructive sleep apnea. 2) It also discusses the importance of weight loss, positional therapy, and lifestyle changes like avoiding alcohol and sedatives as secondary or supplemental treatments. 3) Home sleep testing devices are presented as alternatives to in-lab polysomnography for diagnosing sleep apnea, with minimum requirements for measuring airflow, respiratory effort, and blood oxygenation.

1. Comprehensive Sleep Therapy
AASM Guidelines and what to make
of them
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2. Who is Randy Clare Anyway
• 1990’s – The Silencer
• 2000 – The Diagnostic years
– SensorMedics
– Viasys
– Cardinal Health
– CareFusion
– CPAP Accessories DME
• 2011 – SleepScholar
– DDMEonline.com
– Scottsdalestudyclub.com
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5. Positive airway pressure is the treatment of
choice for mild moderate and severe OSA
and should be offered as an option to all
patients
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7. OSA Patient Diagnostic & Therapy Flow
Patient Motivated to Seek Help
Other Specialist Primary Care Physician Self Referral
10% 80% 10%
Specialist Assessment
Pulmonologist Neurologist Otolaryngologist Psychologist/ Dentist
80% 10% (ENT surgeon) Psychiatrist
5%
Diagnostic Stage at Sleep Lab or in Home
Attended Sleep Lab Unattended Study – Home
(USA)
SNS PSG PPSG HST Device
Diagnosis for half of the Full sleep study in a Less sophisticated studies Studies carried out at the
night and therapy for the sleep laboratory requiring simpler analysis patients home. Attended or
second half unattended
Therapy typically provided by Home Care Provider
CPAP Device Masks (2-4 per year)
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8. CPAP at DME
• Competitive bidding is driving consolidation of
providers (easy for payors not easy for
patients)
• Largest DME providers are
Lincare, Apria, Rotech
• 15-20% of Sleep Labs are now dispensing
CPAP
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9. CPAP at Dental Office?
• Who better than a dentist
• Need an RT due to the Pharmacy Board rules
• 3 month recall
• Steady income Stream
• Unequivocal participation in the medical
model
• Therapeutic neutrality fits the patient
expectation of superlative care
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10. Mask Replacement
• Ideally every 6 months
• Minimum yearly
• Insurance dictates
• Notify customer
• Compliance Program
• Select a reasonably priced mask
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11. HOW OFTEN DO YOU REPLACE YOUR MASK?
n= 2800 patients
• 5% - Every 3 months
• 16% - Every 4 to 6 months
• 14% - Every 7 to 9 months
• 18% - Less than once a year
• 48% - Never
* TalkAboutSleep.Com Survey n=2800
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12. Cleaning & Care of Mask
• Select simplistic mask
• Instruct on cleaning daily / weekly / monthly
mild lanolin free soap
no creams or Vaseline
no rubbing alcohol
no abrasives
clean in A.M.
rinse well
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13. HOW OFTEN DO YOU CLEAN YOUR MASK?
HOW OFTEN DO YOU CLEAN YOUR MASK?
• 26% - Daily
• 7% - 4 to 6 X per week
• 22% - 1 to 3 X per week
• 27% - 1 to 4 X per month
• 15% - less than once a month
• 4% - never
* TalkAboutSleep.Com Survey n=2800
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14. If CPAP use is considered
inadequate based on objective
monitoring and symptom
evaluation, prompt and intensive
efforts should be implemented to
improve PAP use or consider
alternative therapies.
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15. Weight loss should be
recommended for all overweight
OSA patients. Weight loss should
be combined with a primary
treatment of OSA, Because of
the low success rate of dietary
programs and the low cure rate
by dietary approach alone.
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16. Sleep position can affect airway size
and patency with a decrease in the
area of the upper airway, particularly
in the lateral dimension, while in the
supine position.
Positional therapy, consisting of a
method that keeps the patient in a non
supine position is an effective secondary
therapy or can be supplement to primary
therapies for OSA in patients who have a
low AHI in the non supine versus that in
the supine position
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17. Behavioral Strategies
• Weight loss
• Exercise
• Positional Therapies
• Avoidance of Alcohol and Sedatives
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18. Background
• Obesity is the most powerful risk factor for
obstructive sleep apnea (OSA)
• Obesity is essentially the only reversible risk
factor
• Potentially modifiable risk factors for OSA also
include alcohol, smoking, nasal congestion, and
estrogen depletion in menopause.
• Data suggest that obstructive sleep apnea is
associated with all these factors, but at present
the only intervention strategy supported with
adequate evidence is weight loss. ( Young et al. 2002)
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19. Obesity and OSA
• About 70% of those with OSA are obese (Malhotra
et al 2002)
• Prevalence of OSA in obese men and women
is about 40% (Young et al 2002)
• Higher BMI associated with higher prevalence
– BMI>30: 26% with AHI>15, 60% with AHI>5
– BMI>40: 33% with AHI>15, 98% with AHI>5
(Valencia-flores 2000)
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20. Obesity and OSA
• Total body weight, BMI, and fat distribution all
correlate with odds of having OSA
– Every 10 kg increase in weight increases risk by 2X
– Every increase in BMI by 6 increases risk by 4X
– Every increase in waist or hip circumference by 13
to 15 cm increases risk by 4X (Young et al 1993)
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21. October 25 2011 November 28 2011 January 11 2012
1 month on Take Shape for life program > 25 LBs lost
BMI start 35
BMI 3 months later 28
Total weight loss to date 50Lbs
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22. Body Position
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24. A PM should at minimum, record
airflow, respiratory effort, and blood
oxygenation. The type of biosensors used to
monitor these parameters for in-laboratory
PSG are recommended for use in PMs and
include an oronasal thermal sensor to detect
apneas, a nasal pressure transducer to
measure hypopneas, oxymetry, and
ideally, calibrated or uncalibrated inductance
plethysmography for respiratory effort (RIP).
(Consensus)
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25. 17 Channels- Simplified
1.Cannulla airflow
2.RIP derived airflow (backup)
3.Snore from cannulla
4.PAP pressure
5.Snore channel from audio recording
6.Audio playback
7.BPOS – 3 axis gravity sensor
8.Actigraphy
9.Pleth waveform - wireless
10.Heart rate - wireless
11.SPO2 – wireless
12.Thoracic effort RIP
13.Abdomen effort RIP
14.ExG1 – user configurable (ie.,bruxism)
15.ExG2 – user configurable (ie., ECG)
16.Pulse Transit Time
(but in a good way)
17.Heart Rate Variability
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26. Validation Plot for T3-AHI
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27. Embletta and the T3 Evolution of HST
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28. Measuring Bruxism
Software Setup
Electrode Placement
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29. Sample Bruxism Report
There was bruxism, snoring, apneas and hypopneas associated with arterial oxygen
desaturations. The number of bruxism events was 45 providing ABI of 0.9.
The overall apnea/hypopnea index (AHI) was 17.5. The supine apnea/hypopnea index
was 17.5. The mean arterial oxygen saturation was 94%. The lowest arterial oxygen
saturation was 86%
Findings are consistent with
1. Severe sleep related bruxism 327.53
2. Moderate obstructive sleep apnea syndrome 327.23.
Recommendations:
Since the ABI is relatively high, consider a dental consultation for an oral appliance.
This patient has moderate OSA. Therapeutic options include:
The patient may benefit from the use of a nocturnal mandibular repositioning
– appliance. If that line of therapy is to be pursued, the patient should be evaluated by
– a dentist specialized in the treatment of sleep related breathing disorders taking into
– account the presence of Bruxism…. (ask for a full copy of the report)
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31. Three things to consider for Monday
• Do I consider Bruxism when I consult sleep
patients? Sleep for Bruxism patients?
• When I talk sleep do my eyes wander to Neck?
Hips and Belly? Do I estimate BMI?
• Should I talk to my office manager about our
attitude around CPAP? Is there a local DME I
can work with? Should I consider providing
CPAP?
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