Polysomnography | Sleep Scholar

Aerophagia and Gastroesophageal Reflux Disease in Patients using Continuous Positive Airway Pressure: A Preliminary Observation

April 30, 2011 by SleepDT Leave a Comment

Nathaniel F. Watson, M.D.¹ and Sue K. Mystkowski, M.D.²

¹Department of Neurology, University of Washington, Seattle, WA

²Department of Medicine, Division of Pulmonary and Critical Care, University of Washington, Seattle, WA

Address correspondence to: Nathaniel F. Watson, University of Washington Sleep Disorders Center at Harborview, Box 359803, 325 Ninth Avenue, Seattle, WA 98104-2499Phone: (206) 744-4337Fax: (206) 744-5657,; Email: nwatson@u.washington.edu

Received February 2008; Accepted May 2008.

Abstract

Study Objectives:

Aerophagia is a complication of continuous positive airway pressure (CPAP) therapy for sleep disordered breathing (SDB), whereupon air is forced into the stomach and bowel. Associated discomfort can result in CPAP discontinuation. We hypothesize that aerophagia is associated with gastroesophageal reflux disease (GERD) via mechanisms involving GERD related lower esophageal sphincter (LES) compromise.

Methods:

Twenty-two subjects with aerophagia and 22 controls, matched for age, gender, and body mass index, who were being treated with CPAP for SDB were compared in regard to clinical aspects of GERD, GERD associated habits, SDB severity as measured by polysomnography, and mean CPAP pressure.

Results:

More subjects with aerophagia had symptoms of GERD (77.3% vs. 36.4%; p < 0.01) and were on GERD related medications (45.5% vs. 18.2%, p < 0.05) than controls. Regarding polysomnography, mean oxygen saturation percentages were lower in the aerophagia group than controls (95.0% vs. 96.5%, p < 0.05). No other differences were observed, including mean CPAP pressures. No one in the aerophagia group (vs. 27.3% of the control group) was a current tobacco user (p < 0.01). There was no difference in caffeine or alcohol use between the 2 groups.

Conclusions:

These results imply aerophagia is associated with GERD symptoms and GERD related medication use. This finding suggests a relationship between GERD related LES pathophysiology and the development of aerophagia in patients with SDB treated with CPAP.

Citation:

J Clin Sleep Med 2008;4(5):434–438.

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Filed Under: CPAP, Events, Home Sleep Testing, Home Video List, insomnia, Mynewsletter, Newsletter 0810, Newsletter1, Newsletter2, Newsletter3, Newsletter5, polysomnography, sleep apnea, sleep disorders, sleep labs, sleep therapy, Vendors, Videos, Volume 2, Volume 3, Volume 4, Volume 5, Volume 6 Tagged With: polysomnography

Influence of tongue/mandible volume ratio on oropharyngeal airway in Japanese male patients with obstructive sleep apnea

April 29, 2011 by SleepDT Leave a Comment

Shigeta Y, Ogawa T, Ando E, Clark GT, Enciso R.

Source

Department of Fixed Prosthodontics, School of Dental Medicine, Tsurumi University, Yokohama, Japan

Abstract

OBJECTIVES:

The objective of this study was to investigate the influence on the upper airway of the size ratio of tongue and mandible (T/M ratio) with 3D reconstructed models from computed tomography (CT) data.

STUDY DESIGN:

The subjects were 40 OSA male patients. The age of the patients ranged from 25 to 77 years, with an average age of 52.6 ± 12.5 years. The body mass index (BMI) of the patients ranged from 20.1 to 35.8 kg/m(2), with an average BMI of 25.4 ± 3.4 kg/m(2). All patients underwent a full-night polysomnography. The mean AHI for our subjects was 23.6 ± 18.3 events per hour. CT imaging examinations were carried out in each patient. The mandible and airway volume (between posterior nasal spine [PNS] and the tip of the epiglottis) were segmented based on Hounsfield units, automatically or semi-automatically, and their volume was calculated from the number of voxels. The tongue was carefully outlined, and the inside of the tongue was smeared on each of the axial, frontal, and sagittal planes with a semi-automatic segmentation tool. The tongue/mandible (T/M) ratio was calculated from the volume of the mandible and the tongue. In addition, we investigated simple correlations between our anatomical variables and BMI, age, and AHI.

RESULTS:

In this study, the mean tongue and mandible volume were 79.00 ± 1.06 cm(3) and 87.80 ± 1.21 cm(3), respectively. As BMI increases, tongue volume increases (P = .004) and airway volume decreases (P = .021). However, no significant correlation was found between severity of OSA (AHI) and other variables. On the other hand, there was a negative correlation between airway volume and T/M ratio (P = .046).

CONCLUSION:

As tongue volume increases with BMI, the posterior airway is affected, and thus is likely to be involved in the development of OSA; however, in this study there was no correlation between the severity of sleep apnea (AHI) and other variables in the study.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011 Feb;111(2):239-43.

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Filed Under: Dental, dental appliances, Events, Home Sleep Testing, insomnia, polysomnography, sleep apnea, sleep disorders, sleep labs Tagged With: pharyngometry, polysomnography

Comparative Effects of Two Oral Appliances on Upper Airway Structure in Obstructive Sleep Apnea

April 13, 2011 by SleepDT 2 Comments

“Good article just published in the latest edition of Sleep. It compares a MAS device with a TSD – the results are interesting where both appliances worked, at least in the responders, but the imaging showed some differences. This data reinforces the need for tongue position and management with OAT like The Moses appliance does”

Ashley

Kate Sutherland, PhD¹^,²; Sheryn A. Deane, MDSc³; Andrew S.L. Chan, MD, PhD¹^,²^,⁴; Richard J. Schwab, MD⁵; Andrew T. Ng, MD, PhD⁴; M. Ali Darendeliler, PhD³; Peter A. Cistulli, MD, PhD¹^,²^,⁴

¹Centre for Sleep Health and Research, Department of Respiratory Medicine, Royal North Shore Hospital, St Leonards, NSW, Australia; ²Woolcock Institute of Medical Research, University of Sydney, NSW, Australia; ³Department of Orthodontics, Faculty of Dentistry, University of Sydney, Sydney Dental Hospital, NSW, Australia; ⁴Department of Respiratory and Sleep Medicine, St George Hospital, University of New South Wales, NSW, Australia; ⁵University of Pennsylvania, Philadelphia, PA

Oral appliances are increasingly being used for treatment of obstructive sleep apnea (OSA). Mandibular advancement splint (MAS) mechanically protrudes the mandible, while the tongue stabilizing device (TSD) protrudes and holds the tongue using suction. Although both appliances can significantly improve or ameliorate OSA, their comparative effects on upper airway structure have not been investigated.

Design:

Cohort study.

Setting:

Sleep Investigation Unit.

Patients:

39 patients undergoing oral appliance treatment for OSA.

Interventions:

OSA patients underwent magnetic resonance imaging (MRI) of the upper airway during wakefulness at baseline and with MAS and TSD in randomized order. Treatment efficacy was determined by polysomnography in a subset of 18 patients.

Measurements and Results:

Upper airway lumen and surrounding soft tissue structures were segmented using image analysis software. Upper airway dimensions and soft tissue centroid movements were determined. Both appliances altered upper airway geometry, associated with movement of the parapharyngeal fat pads away from the airway. TSD increased velopharyngeal lateral diameter to a greater extent (+0.35 ± 0.07 vs. +0.18 ± 0.05 cm; P < 0.001) and also increased antero-posterior diameter with anterior displacement of the tongue (0.68 ± 0.04 cm; P < 0.001) and soft palate (0.12 ± 0.03 cm; P < 0.001). MAS resulted in significant anterior displacement of the tongue base muscles (0.35 ± 0.04 cm). TSD responders (AHI reduction ≥ 50%) increased velopharyngeal volume more than non-responders (+2.65 ± 0.9 vs. –0.44 ± 0.8 cm³; P < 0.05). Airway structures did not differ between MAS responders and non-responders.

Conclusions:

These results indicate that the patterns and magnitude of changes in upper airway structure differ between appliances. Further studies are warranted to evaluate the clinical relevance of these changes, and whether they can be used to predict treatment outcome.

SLEEP2011;34(4):469-477.

Full text with images: http://www.journalsleep.org/ViewAbstract.aspx?pid=28089

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Filed Under: Events, Home Sleep Testing, Home Video List, insomnia, Mynewsletter, Newsletter 0810, Newsletter1, Newsletter2, Newsletter3, Newsletter5, polysomnography, sleep apnea, sleep disorders, sleep labs, Vendors, Videos, Volume 2, Volume 3, Volume 4, Volume 5, Volume 6 Tagged With: sleep appliances

A Daytime, Abbreviated Cardio-Respiratory Sleep Study (CPT 95807-52) To Acclimate Insomnia Patients with Sleep Disordered Breathing to Positive Airway Pressure (PAP-NAP)

April 11, 2011 by SleepDT Leave a Comment

Barry Krakow, M.D.^1,2,3; Victor Ulibarri, B.S.^1,2; Dominic Melendrez, B.S.^1,2; Shara Kikta²; Laura Togami²; Patricia Haynes, Ph.D.⁴

¹Sleep & Human Health Institute, Albuquerque, NM; ²Maimonides Sleep Arts & Sciences, Ltd, Albuquerque, NM; ³Los Alamos Medical Center Sleep Laboratory, Los Alamos, NM;⁴Department of Psychiatry, University of Arizona, Tucson, AZ

Study Objectives:

To assess the impact of a daytime sleep medical procedure–the PAP-NAP–on adherence to positive airway pressure (PAP) therapy among insomnia patients with sleep disordered breathing (SDB)

Methods:

The PAP-NAP is based on Current Procedural Terminology (CPT) codes and combines psychological and physiological treatments into one procedure, which increases contact time between SDB patients and polysomnography technologists to enhance PAP therapy adherence. Using a Sleep Dynamic Therapy framework, explicating SDB as a mind-body disorder, the PAP-NAP includes mask and pressure desensitization, emotion-focused therapy to overcome aversive emotional reactions, mental imagery to divert patient attention from mask or pressure sensations, and physiological exposure to PAP therapy during a 100-minute nap period. Patients treated with the PAPNAP test (n=”39)” were compared to an historical control group (n=”60)” of insomnia patients with SDB who did not receive the test.

Results:

All 99 insomnia patients were diagnosed with SDB (mean AHI 26.5 + 26.3, mean RDI 49.0 + 24.9), and all reported a history of psychiatric disorders or symptoms as well as resistance to PAP therapy. Among 39 patients completing the PAP-NAP, 90% completed overnight titrations, compared with 63% in the historical control group; 85% of the nap-tested group filled PAP therapy prescriptions for home use compared with 35% of controls; and 67% of the nap-tested group maintained regular use of PAP therapy compared with 23% of the control group. Using standards from the field of sleep medicine, the nap-tested group demonstrated objective adherence of 49% to 56% compared to 12% to 17% among controls. All studies were reimbursed using CPT 95807-52.

Conclusion:

In this pilot study, the PAP-NAP functioned as a brief, useful, reimbursable procedure to encourage adherence in insomnia patients with SDB in comparison to an historical control group that did not undergo the procedure.

http://www.aasmnet.org/jcsm/ViewAbstract.aspx?pid=27183

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New Clinical Practice Guidelines Issued for Tonsillectomy

January 5, 2011 by SleepDT Leave a Comment

The American Academy of Otolaryngology & Head and Neck Surgery (AAO-HNS) has issued new clinical practice guidelines which states most children with frequent throat infections do not need tonsillectomy surgery.

The practice guidelines is published in the January issue of Otalaryngology – Head and Neck Surgery.

Click here to read the full article.

http://oto.sagepub.com/content/144/1_suppl/S1.full

The AAO-HNS is the world’s largest organization representing specialists who treat the ear, nose, throat, and related structures of the head and neck. The Academy represents more than 12,000 otolaryngologist—head and neck surgeons (ENTs) who diagnose and treat disorders of those areas.

The guidelines was developed using a systematic literature search which was condensed into evidence-based statements with associated balance of benefit and harm. The guideline panel members were chosen to represent fields of sleep medicine, advanced practice nursing, anesthesiology, infectious disease, family medicine, otolaryngology–head and neck surgery, pediatrics, and consumers.

The panel notes “Guidelines are never intended to supersede professional judgment; rather, they may be viewed as a relative constraint on individual clinician discretion in a particular clinical circumstance.”

The guideline panel recommendations—

1. Watchful waiting for recurrent throat infection: Clinicians should recommend watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years.

2. Recurrent throat infection with documentation: Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and one or more of the following: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for Group A β-hemolytic streptococcus (GABHS).

3. Tonsillectomy for recurrent infection with modifying factors: Clinicians should assess the child with recurrent throat infection who does not meet criteria in Statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of peritonsillar abscess.

4. Tonsillectomy for sleep-disordered breathing: Clinicians should ask caregivers of children with sleep-disordered breathing and tonsil hypertrophy about co-morbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems.

5. Tonsillectomy and polysomnography (sleep study): Clinicians should counsel caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing.

6. Outcome assessment for sleep-disordered breathing: Clinicians should counsel caregivers and explain that SDB may persist or recur after tonsillectomy and may require further management.

7. Intraoperative steriods: Clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy.

8. Perioperative antibioticse: Clinicians should not routinely administer or prescribe perioperative antibiotics to children undergoing tonsillectomy.

9. Postoperative pain control: The clinician should advocate for pain management after tonsillectomy and educate caregivers about the importance of managing and reassessing pain.

10. Posttonsillectomy hemorrhage (bleeding): Clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually.

Source reference: ”Clinical Practice Guideline: Tonsillectomy in Children” Otolaryngoly Head Neck Surg 2011

Filed Under: clinical practice guidelines, ear nose throat, family medicine, head and neck surgery, medical record, neck surgeons, Otalaryngology, peritonsillar, polysomnography, Postoperative, Posttonsillectomy, sleep medicine, throat infection, throat infections Tagged With: clinical practice guidelines, health, Otalaryngology

Home Testing for the Sleep Centers

December 20, 2010 by SleepDT Leave a Comment

Written by Chris Vu, Dec 20th 2010:

Sleep medicine in the Home and the Lab

With each passing month, sleep professionals continue to ponder the best way to use in-lab sleep testing in conjunction with proper home testing. Economic pressures are driving the evolution, which began in earnest 18 months ago when Medicare allowed the diagnosis of apnea, in certain patients, with home testing. “Medicare again has announced in certain areas they are reducing the reimbursement for full PSG, and this has been the trigger for some to try to be smarter about sleep testing. The financial pressures on labs have made many people more willing to accept home testing.

Specifically, the Centers for Medicare and Medicaid Services (CMS) targeted a local coverage area for reimbursement reduction on full polysomnography, a trend that is likely to continue. In a separate local coverage determination (LCD), CMS stated that starting in January you must be AASM-accredited, JCAHO accredited, or have a board-certified doctor as your medical director to bill Medicare for studies. Most hospital facilities already have that, but it will have a dramatic effect on the alternate care sites—the off-hospital sleep labs. A greater percentage of those are not AASM accredited. These rules may improve labs, but will probably limit the number of people who can get care because fewer labs will be available.

At least for uncomplicated patients, the medical community has come to accept home sleep testing is clinically effective in appropriate patients. Full PSG will likely never go away, at least in the foreseeable future, because home studies are simply not indicated for everybody.

Experts acknowledge that many in the sleep community are still struggling to reconcile the high clinical standards achieved in sleep labs with the home environment. Right now, the opportunity for manufacturers who have a device that can comply with the high standards of the AASM. Those who can, will be successful. The tradeoff is that those high-standard devices can often be more difficult and more cumbersome to use.

On the other side of the Atlantic, these important questions have largely been answered, with greater acceptance of home testing found in much of Europe. We believe that outside the U.S. the number one opportunity is full PSG unattended, which is a Type 2 device. Reimbursement outside the U.S. also continues to decline. The full sleep labs must figure out a way to stay in business, and the next step for them is to do unattended full PSGs. In Japan, they have a rule this year where you get the same reimbursement whether the test is attended or not. The big incentive is to do unattended studies, because the reimbursement in Japan is the highest in the world.

Filed Under: CMS, Home Sleep, Home Testing, hospital sleep labs, Medicare, polysomnography, sleep apnea, Sleep Centers, sleep labs, unattended studies Tagged With: home sleep, polysomnography

	Randy Clare Managing Editor of SleepScholar and RespiratoryScholar
	Dr. Steve Carstensen Pankey Institute for Advanced Dental Education, American Academy of Dental Sleep Medicine.
	Ruchir Patel MD Founder & Medical Director at the Insomnia and Sleep Institute of Arizona.
	Dr. John S. Viviano AADSM Diplomate and member of various sleep organizations. Has lectured internationally on the treatment of Sleep-Disordered Breathing and the use of Acoustic Reflection.
	Jeffroy Wyscarver President, DDME Online, Sleep Lab Technology and Services for the Dental Community.
	Claude Albertario RPSGT, speaker, author and mentor in the field of sleep diagnostics with 25 yrs of management experience in one of New York's premier sleep centers.
	Joseph Anderson Co-Founder and Director of Education for Priority Health Education and Priority Scoring.
	Todd Austin Managed sleep labs and has 15 experience in sleep diagnostics and therapeutic systems. .
	Marietta Bibbs Sleep specialist and manager of Sleep and Neurodiagnostics at Morton Plant Mease Healthcare.
	Bradley Eli DMD, MS Director, San Diego Headache and Facial Pain Center / Sleep Treatment and Research Institute
	Edward Grandi Executive Director of the American Sleep Apnea Association.
	Edward Michaelson MD Board Certified in Pulmonary Medicine, Internal Medicine and Sleep Medicine
	Ashley Truitt Founder & Director of Dental Sleep Medicine Worldwide, Co-Founder of TPT Dental.

Influence of tongue/mandible volume ratio on oropharyngeal airway in Japanese male patients with obstructive sleep apnea

Source

Abstract

OBJECTIVES:

STUDY DESIGN:

RESULTS:

CONCLUSION:

New Clinical Practice Guidelines Issued for Tonsillectomy

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