It is always a challenge when we have met a person for the first time and we ask a few questions and than we have to help them choose a mask that will work for him or her. This is a very interactive experience that can take a short period of time, or what usually happens is that it takes quite a bit of time making the decision. There are basically five ways to make this experience easier and more successful

1. You need to come in with your mind open. Many people go into the experience thinking they know what want in a mask. This may be because a friend has a CPAP and is successful with a mask they chose and so you figure it will work for you. It could also be because you went researching on the internet and thought the newest mask on their looked like something you want. The truth is that there are so many masks on the market because there are that many different needs for different people.
   
   
2. Claustrophobia does not mean that a smaller mask is a better mask. The fact is that nasal pillows and can sometimes feel stronger and make you feel more claustrophobic. A mask that allows you to breathe through your mouth may be more comfortable. There are masks on the market that do not block your line of vision and will make you feel more comfortable.
   
   
3. If you take steroids or blood thinners your skin will react differently to masks. Your skin will be more fragile. The person working with you needs to be aware of this so they can choose a mask that puts less pressure on the bridge of your nose. There are extra cushions if needed but the ideal is to find the right mask that does not put pressure on your face.
   
   
4. Do not be afraid to ask to try a different mask. You will be using this mask for a long period of time and you have the right to try as many masks as you want. You are not annoying the technologist. We would rather have someone tell us that there is a problem with the mask during the night than to find it out after the test when they cannot do anything about it.
   
   
5. If you think you will need time to get used to the mask and the therapy see if you can come in before the night of your study. In many labs they will have you come in for a PAP NAP during the day. They will allow you to trial masks and get used to the pressure during the day. It is a great opportunity to take your time and not feel the pressure of having to go to sleep on the machine right away.
   
   

CPAP therapy can help you to improve your health and allow you to feel more energetic. Being successful using the therapy requires that you find just the right mask whether it is a full face mask, nasal mask or nasal pillows. The goal is for you to find a mask that will allow you to sleep comfortably and breathe easily.

I hear the complaint all the time, “ that is not in my job description.” People look at jobs as how to do the least amount of work for the most amount of money. They may even resent the owner of the business because he or she is making money. The fact is that people should look at their job as a business that they own and so they should step up and contribute when they can.

Today while I was working on my sleep studies from this weekend the marketing and owner came up to me and asked me to write an advertising article for a local newspaper and I had a two hours to complete it. It was challenging but I was able to get it done and working with the marketers we had a great product to put in the paper.

These little extra activities that help the business also helps me because I am helping to make the business grow and that gives me more job security. It also gives me new and interesting experiences that I can use in the future.

It also helps me be a more valuable employee. That little extra step allows me to know that I have so much more to contribute. It also shows me that there are skills that I possess that go far beyond sleep and management. Skills that I can put toward outside interests and teaching.

More people are being diagnosed with obstructive sleep apnea every day.  With this increase it is important to develop new ways of treating this disorder.  PAP, positive airway pressure, devices are considered the gold standard of treating sleep apnea.  The problem is that there are patients who are unable to tolerate this therapy.  One of the options for people who are unable to tolerate PAP is an oral appliance or dental device. 

These devices work best for those who have mild to moderate sleep apnea.  Mild sleep apnea is defined as 5-15 respiratory events per hour.  Moderate sleep apnea is defined as 15-30 respiratory events an hour.  Anyone who has more than 30 respiratory events per hour is considered to have severe sleep apnea and although they can use an oral appliance it is not as successful in treating this disorder.

There are two different types of oral appliances, mandibular advancement devices and tongue retention devices.  The MRA devices work by advancing the mandible or lower jaw forward 6-11mm to help open the back of the airway.  TRA devices work by pulling the tongue forward and that helps to keep the airway open. 

MRA devices are generally fitted and adjusted by a dentist.  Ideally you should go to a dentist that specializes in sleep dentistry.  You can get a list of registered dentists at http://www.aadsm.org/FindaDentist.aspx.  These dentists are board certified in this specialty and have the ability to fit you with the correct device and to do any follow up testing you may need.  The dentist will take an impression of your teeth and create an oral appliance that will fit you and cause the least amount of side effects while opening your airway sufficiently to correct your sleep apnea. 

The TRA devices are also fitted by a dentist however there are several styles that are available to buy directly and to then self-fit by the boil and bite method.  These particular devices work best for patients who have an oversized tongue. 

Some of the side effects of these devices are drooling, your teeth shifting, tooth pain and sometimes jaw pain.  According to current research it does not appear that the devices contribute to TMJ.

Patient with severe sleep apnea may consider using an oral appliance in conjunction with the CPAP because you might be able to decrease the pressure of the PAP device. 

The ability to have a choice of therapy for obstructive sleep apnea is a great advance for people.  Not everyone can tolerate CPAP or BIPAP but they still need to have some treatment for their sleep disorder. 

In today’s job market people are looking at new careers to allow them to advance.  Sleep technology is a young field that is starting to organize, become licensed, and is need of some great people.  The sleep labs are need of people who are willing to go for training and learn the field of sleep and to continue to learn and grow while they are working.  I will be sharing some basic knowledge of what is needed to successfully enter the field.

What skills do you need to be a successful sleep technician?  The first and most important skill is to have people skills.  You will not only be working with patients to set up for the test but you may also be working with other people.  You have to have a sense of independence because you may be working alone on some nights and be responsible for your patients and for clinical decisions during your shift.  You have to have a basic technical ability.  Much of what you will be doing has a great deal to do with understanding both electrical theory and anatomy and physiology.  The last skill you will need is the ability to work night shift.  Most of the jobs are night shift and are 7pm to 7 am or 8pm to 6am.  No matter which type of shift you work learning how to deal with the change is schedule is a large part of preparing for the field.

Where do I get education to become a sleep technician?  There are a great many ways to enter the field.  There are still many opportunities for on the job training in states that do not have licensing laws that prevent it.  This is a good choice of the facility has a strong training program.  There are also short programs called A-STEP classes these last 40 hours and will require some classroom work as well as some clinical and lab time.  These classes will help to prepare you not just to work in the field but as a first step toward getting your accreditation.  You can also find college programs being developed throughout the country.  Some programs are at private college with an Associate’s degree in Neurodiagnostics and some are add on certificates to programs such as Respiratory Therapy. 

Where do I find employment opportunities?  There are jobs in the field of sleep throughout the country.  You may be working in one of three types of facility, hospital based labs, doctor practice labs or independent diagnostic testing facilities.  All of these facilities have their benefits and their drawbacks.  The best thing you can do is explore your opportunities as they become available. 


Will there be any required testing or licensing as a technician?  This is a very young profession and as such licensing is just starting to happen.  You will check your state to find out if you will need a license to work.  You will also need to consider getting your sleep credentials as states that are licensed require them.  Even if you are not in a state that requires credentials you should get them because it will allow you to be eligible for more jobs and to be able to move up in the field after you have some experience.  There are currently three different groups offering credentials.  The NBRC, National Board of Respiratory Therapists, is the testing company for respiratory therapist and offers a specialty test for sleep technicians.  The BRPT, Board of Registered Polysomnographers, is the board that gives two tests in sleep; an entry level certification test that you can take once you completed half of the online A-STEP courses and  have three months of experience in sleep and the Registry exam which has different rules depending on how you entered the field.  The RPSGT credential is considered the gold standard of testing currently.  The final group to offer testing is the ABSM, American Board of Sleep Medicine.   They will be offering a new test starting in the fall of 2011.  This test was written by the physicians who are in the field of sleep.   No matter which test you take credentials are a necessity if you want to advance in this field.

What does the future of sleep technology look like?  The hardest question to answer is what does the future hold.  There has been the introduction of many new technologies over the past ten years.  These have allowed for easier testing of patients.  There is also the fact that the public is just now getting educated on the issue of sleep and sleep disorders.  A majority of people suffering from sleep disorders still have not been treated.  This leaves the future need for sleep testing open and growing. 

When looking at new career fields it is always good to find a career that will match your personality and lifestyle.  Although this field may have a great deal growth potential you will not be happy unless you fit into the demands of the job.  Take your time, do some research and visit a sleep lab before you make any decisions. 

There are many people who believe they can live on very little sleep.  Although not everyone needs 7-9 hours of sleep there are very few people who can go on less than 7 hours of sleep.  The fact is that lack of sleep has been linked to many health problems that you might not have initially associated with a lack of sleep.

 

According to the National Sleep Foundation approximately 1/3 of Americans are chronically sleep deprived.  This sleep deprivation can be linked to things like daytime sleepiness and irritability as well as memory loss and the inability to concentrate.  This can affect our day to day activities and make things like driving more dangerous than they have to bed.

It also had a strong effect on our weight.  When we are sleep deprived we tend to eat more at a meal and we tend to eat more often to try and get over our fatigue.  This contributes to obesity.  It is something that is very common especially in night shift workers who usually only get 4-5 hours of sleep a day.

Sleep deprivation has also been associated with heart disease and early mortality.  The thought is that the stress caused from the lack of sleep on our body contributes to these issues. 

Why do so many people believe they can go without sleep?  Many people do not understand the necessity of sleep for their body.  Sleep allows people to reset their brain and health their body.  They also do not understand that they will not feel tired if they are over stimulated or over exposed to light, two problems we have in the computer age. 

How do you determine if you have a sleep issues?  If you have health issues such as high blood pressure, diabetes or heart disease that takes more than 1 medication to control you might want to look at your sleep habits.  If you have depression, daytime fatigue or fall asleep as soon as you get home these are good signs that you might want to go to bed a little bit earlier.  Sometimes if we have an increase in our appetite although we have not changed our habits it can be a sign that we are actually tired.

The best way to evaluate if you really have a sleep issue is to do a two week sleep diary.  This can be simple notebook that has the time you go to bed and the time you wake up in it.  You should also include how much caffeine you have had during the day, any exercise you did any unusual activities such as parties or cleaning the garage.  Looking at the patterns of sleep over two weeks can give you an idea if you problem is as simple as you do not have a regular bed time or that the television is keeping you awake or it can tell you if maybe it is time to talk to your doctor. 

There are some people who may be able to get by on less sleep but if you want to stay healthy, and be alert getting 7-9 hours of sleep should be your goal.  It may take some small changes in your daily habits but in the end the health benefits are worth it.

Dr Steven Park is a surgeon in New York who specializes in helping those with sleep apnea and other sleep disorders find surgical solutions to their issues. He has written a fantastic book Sleep, Interrupted . He has made sleep his specialty and gives monthly free webinars to answer patient's questions, educate about the newest research in sleep and to interview the top people in the field.

  His next webinar is Tuesday 7/12/2011 at 8pm. If you are interested you can sign up at http://doctorstevenpark.com/ask-dr-park-teleseminar

I received an E-mail from the National Association of Respiratory Therapists the other day saying congratulations on the anniversary of you credentials.  It made me thing how long I have been around the field of respiratory and sleep and what changes have I seen.  It also allowed me to draw several parallels from the two fields. 

When I went to school in Paramus NJ back in the 1980’s Respiratory therapy still had many OJTs in the field.  They did not have licensure.  They had many school with certificate programs rather than AAS degrees and there were only a handful of BS degrees in the country.  It was a young field with a great deal of potential and was finding its way in the healthcare arena. 

I was truly lucky I had the best instructors who allowed me to see a great future in the field and drove me to be the best therapist I could be.  They encouraged the whole class to take not just our CRTT exam but to take our RRT as soon as we were eligible.  They taught us not just the minimum we needed to pass the exams but also those skills we would need to grow with the field.  It was truly a program ahead of its time.  When I look at where many of my classmates are I see several who have run departments and gone into management and I believe there are a teacher or two from then as well. 

When I look at the field of sleep which I have been in for 10+ years ( I know where does the time go) I see so many parallels and I am excited about its future because I see so many great people stepping up to the plate and leading.  I see programs starting to develop across the country.  I have even had a hand in one.  I see people taking on leadership roles and state societies emerging and helping to develop licensure laws.  I even see a future where sleep will need its own degree program in order to keep up with the field as a while.  That is if we can stop the infighting and focus on the future instead of who is right and who is wrong.  We need to take that leadership on ourselves instead of letting other people take it over. 

What do I see has happened to me and my job since 1987 when I graduated my Respiratory program, I see a world where we have changed how patients are treated when it comes to breathing disorders.  I see a world where care has more scientific study than ever before.  I see a great deal of potential.

Your doctor has asked you to come to the sleep lab for a sleep study.  You make the appointment, fill out all the paperwork and arrive for your study.  Your technician introduces themselves and gives you a tour of the lab.  You see where the technician sits and you think.  Really what are they looking at?

Here is a small behind the scenes look at what the technician will be seeing during the night.  It will also explain why there are so many wires and why it takes so long to attach them all.

There are three images that the technician will be looking at.  The video of you, the electrical signals the wires are giving off and the signal from a CPAP machine if it is being used.

The video is used for several things.

•  Determining what position you are sleeping.
•  To watch if you need assistance
• To watch for activity such as leg and arm movements, movement during REM and Parasomnias, such as sleepwalking.

The CPAP machine is to assist with your breathing if you have been diagnosed with obstructive sleep apnea.  We watch to see what pressure you are on; if the mask you are using is having issues or the volume of air you are moving.  This helps us to determine if the pressure is working for you or if we need to increase or decrease the pressure.  It also helps us determine if we may have to change the mask you are wearing.

The most complex image watched is the computer screen with the electrical impulses from your body.  Although the screen can be set up differently depending on the type of study and the facility, all the items on the screen are the same.  The first thing the technician will be watching are the wires from your head.  Theses wires tell us when you are awake and when you are asleep.  It will also tell what stage of sleep you are in.  There are 4 stages of sleep that people cycle throughout the night. 

On the face we monitor eye movements and chin movements.  The eyes and chin help us to determine when you reach a stage of sleep known as REM, when you dream.  The chin leads also allow us to know if you grind your teeth in your sleep.  This problem can sometimes cause disruption of sleep.

We use several items to monitor your breathing. 

•  A cannula that monitors the change in pressure when you breathe
•  A thin wire by your nose and mouth that measure changes in temperature when you breathe.  This allows us to determine when you are breathing
•  Two belts, one around your chest and one around your belly, which measure the movements of breathing.  The reason for the two belts is because your breathing can happen more in the belly than chest or vice versa.  It also tells us when you are having trouble breathing because the chest and belly will move opposite of each other.
•  We also have a microphone to measure snoring which may be on your neck or it may be on your forehead.

You can see that we are very careful about how we monitor your breathing because we need to not only know when you are breathing but if you are having issues what type of problem it could be.

We also monitor you heart and your oxygen levels.  We use a clip on your finger that measures the oxygen by shining a red light through your finger.  The amount of light the sensor reads is based on the amount of oxygen attached to your red blood cells.  The heart rate it measure by two electrodes placed on the chest.

The final signal comes from the electrodes placed on the legs.  Some people have muscle movements during the night, the leg leads will monitor for those movements.

As you can see the technician is quite busy during the night evaluation the signals and video they are viewing throughout the night.  Their job is to make sure the signals are as clear as possible for the physician to read and to understand what is going on during the night so they can be of assistance to you, their patient, when needed.

I hope you will feel a little more comfortable when you visit the lab for your study.

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One of the biggest issues people have with CPAP is that if they sleep in any position other than on their back the mask slips, slides, leaks or honks.  The goal is for you to be able to use your CPAP every night and for you to get a restful night sleep.   The solution comes in several little changes and maybe one big change.

•        Make sure you are not over tightening or under tightening your mask.  The newer masks are designed to be put on with the machine on so that the mask makes an air cushion against your face.  This will allow the mask to shift slightly when you move,
•      Look at your pillow.  Sometimes it pays to invest in a good pillow.  There are several companies online who sell pillows designed specifically for use with your mask.  Contourliving.com has two pillows that are designed with cutouts indentations your mask will fit into when you roll over.  It also gives you support on your neck and head.  These are latex foam.  Papillow.com has created a more traditional pillow that is shaped so the neck support is wider than the rest of the pillow so the mask fits and does not shift.  They also offer a travel size pillow.
•      A hose support might help.  Sometimes it is not the mask that causes the mask to shift.  Depending where you have your machine you might consider using something to support the hose so it does not move around quite so much.
•    Get a leak cushion. There are several brands of gel cushions that fit over your nose and help to make a better seal.  If you have a narrow bridge to your nose this may help.  It also may help if you tend to wake up with a sore bridge to your nose. 
•    Change your mask.  If all else fails you may not have the best mask for you.  Respironics has an interesting new mask called the True Blue nasal mask.  It is a unique design that will adjust without shifting on the face.  The Resmed Mirage FX and Swift FX have low profiles and because of the soft texture that allows it to adjust to your movements.

No matter what the most important thing you need to do is find a way to make your PAP therapy work for you.  The doctor who ordered the machine and the technicians who tested you and set up the machine are your best resources; you just have to ask the questions.

The last two years have seen a great deal of change in health insurance and this has affected the care of people with sleep apnea.  It is part of the job of a sleep lab manager to keep up with these changes so we can make sure that the patient receives the best service possible.  The biggest problem we face is that many times the patient does not understand the changes that have taken place.  If you are able to explain these changes effectively you might avoid a patient’s negative experience.

 

One big issue seems to be the most difficult with those patients who need a replacement machine.  People who have older machines many no longer qualify for CPAP simply because the qualifications have changed.  Respiratory events have a different definition today than they did 10 years ago.  Documentation was also different 5 or more years ago.  You need to make sure you have documentation that meets current standards when going to order a new machine.

The other issue that is becoming more influential on sleep patients is riders and deductibles.  Today many patients have significantly higher deductibles they have to meet.  This can cause financial hardships in having tests done and getting their CPAP equipment.  Many people do not know the nuts and bolts of their insurance policy.  If we can be of help in explaining what is going on and why we bill the way we do they will leave with a positive experience even if they do not end up having a test due to the cost.  But if all you say is that “your insurance company says that your test will cost you x dollars,” the patient will only leave with a feeling of being short changed by your facility.  Instead if we understand that the patient has a large deductible and that although when you visit the doctor you pay a copay if does not cover deductibles, instead the deductible applies only to everything that happens outside the doctor’s office, they will get a clearer picture.

It also helps to reduce the non pays for the lab.  In our lab we rarely get an insurance company denial.  The ones we do get usually get paid when we submit additional paperwork.  This reduction in denials helps us make more cash flow overall and allows us to grow.  It gives everyone in the lab job security. 

In the end it is important to be a strong resource for our community.  Knowledge about how insurance works is a great way to start.  If you are an avid reader or you have access to the people in the billing department of the practice you can gain the knowledge you need.