Category Archives: Standards of Practice

“IS A DEDICATED SLEEP PRACTICE RIGHT FOR ME?” Part 3 “Combined Therapy”

I thought it would be just another presentation until I stood before the group and saw first handed the dynamics and heartbreaking challenges they live with – everyday. Easter Seals provides a yearly meeting for parents of Down syndrome children, and this year they had invited me to give a presentation entitled “Sleeping with Down syndrome.”

Parents of Down syndrome children deserve to be applauded and served well  by all of us.  From birth their child/children suffer with classic OSA symptoms which

America's most successful Sleep Apnea Dentist
America’s most successful Sleep Apnea Dentist

often go unnoticed and undiagnosed.  DS children usually have short, wide necks, the airway is narrow making breathing difficult; the tongue is enlarged and swallowing is continuously problematic; the weak muscle tone (hypotonia) from infancy adds to the probability of OSA.

Throughout the presentation, I struggled to keep my emotions ‘in check’ as the facial expressions of each parent seemed to grasp the little bit of hope offered through oral appliance therapy. As the ‘teacher’ for the moment, I became the student, realizing the true struggles this often-ignored and unnoticed group of people encounter each day. Though there is no cure for DS, we as dentist have the training and ability to offer some relief that can make an enormous difference in their world and ours. An estimated 250,000 people in the United States have this condition; Down syndrome occurs 1 in every 830 newborns. Source: http://ghr.nlm.nih.gov/condition/down-syndrome

At the close of the presentation, Tom anxiously approached me and introduced himself as one of the proud fathers of a DS child. Tom then proceeded to tell me his story, “Everything you said described me.” He continued: “I’m an executive at Caterpillar (world headquarters located in Peoria, Il) and I struggle to stay awake throughout the day. I fell asleep at a stoplight, waiting for it to turn green, so my wife began driving me to work. We have 8 children so this was difficult for her.  A few years back, my doctor recommended nasal pillows with a chinstrap; I couldn’t tolerate the chinstrap so my doctor put me on a full face mask, the pressure was at a 22 and complications set in and I found myself unable to were it.

My doctor then recommended our last option, the UP3 surgery. I knew it would be a difficult surgery, but I was desperate and felt like this was my last chance.  The surgery helped for a short time, but then the drowsiness returned.  Last week I fell asleep in the middle of my sentence while talking to a co-worker. My wife and I have decided that I need to retire and apply for disability.” Tom was 51 years old with a great career and large family responsibilities.

A report from Health Advocate explains Tom’s case very well: “Sleep deficits in general are lined to an increased risk of cardiovascular disease, stroke, obesity and hypertension.  These chronic conditions are a major factor in soaring healthcare costs for U.S. companies accounting for 70-80 percent of their overall healthcare costs.” Another eye-opening statement from the same report says: “The effects of sleep loss on work performance are costing U.S. employers tens of billions of dollars a year in lost productively.  Its time for American workers and employers to make sleep a priority.”

My first concern was that Tom was untreated and needed help now. The following day, Tom presented as a patient in my office and we began MRA treatment.  His AHI score was 115.  We delivered his appliance and he returned for his two-week follow up my office.  He was driving again and looked like a different man!  Tom was elated, but I knew he was still in danger so I called his pulmonologist and arranged for a split night PSG using the appliance only for the first part of the test. Tom’s AHI was reduced to a 31 with the appliance alone, then a minimally invasive CPAP(nasal pillows only) combined with the Herbst MRA was titrated and the final AHI was reduced to a 4 with the CPAP pressure at a 10.

In the eyes of the pulmonologist, I wasn’t just a dentist, but rather a sleep specialist, which I could not claim. He saw me as this due to my stand-alone sleep practice, which has my complete focus. We began a series of conversations and determined the best treatment for OUR patient was a combined therapy approach. With the oral appliance in place and functioning as the ‘work horse’ we applied nasal pillows and brought his AHI to a 4. It is important to note that the appliance had to be perfect; I use Gergens Orthodontic Lab because I can depend on the consistency of the product they provide. Combined therapy was the right choice for in this case and I continue to evaluate combined therapy for every case.

At Tom’s one-year recall appointment his AHI was stable at a 4, the appliance was doing all that it is designed to do.  Tom was on his game at work and at home. His wife was no longer driving him to the office and he was staying awake during family time. Conversations about disability were history! As I walked out of the treatment room Tom stood up, put his hand on my shoulder and said, “Wait a minute Doc, I just want to say thank you for giving me my life back.”

Quality of life is more valuable than position, titles, or money. When we, as dentist, can change the course of a life due to treatment that is within our means to provide, what a privilege!  It also heightens our responsibility to society and building relationships with all medical providers.

 

David Gergen CDT opened his family-owned Gergen's Orthodontic Lab in Phoenix, AZ in 1986 and now employees over 80 people. David Gergen has been a nationally respected dental lab technician for over 25 years. He received the award for "The Finest Orthodontic Technician in the Country" given by Columbus Dental in 1986. He also received a lifetime achievement award by Dr Harold Gelb Academy as Americas greatest Orthodontic technician of all time, in 2012. He has worked for some of the pioneers in the orthodontic and sleep dentistry fields. Gergen and his father John Gergen began Gergen Orthodontic labs in 1984 and have grown it into one of the most respected labs in the country. One of his proudest achievements is receiving The National Leadership award for Arizona Small Businessman of the Year in 2004. David is the Dental Director of the American Sleep and Breathing Academy and he has also taken a spot at Tufts University teaching seminars for the Continuing-Ed program on Dental Sleep Medicine.
David Gergen President, Gergen’s Orthodontic Lab

David Gergen CDT opened his family-owned Gergen’s Orthodontic Lab in Phoenix, AZ in 1986 and now employees over 80 people. David Gergen has been a nationally respected dental lab technician for over 25 years. He received the award for “The Finest Orthodontic Technician in the Country” given by Columbus Dental in 1986. He also received a lifetime achievement award by Dr Harold Gelb Academy as Americas greatest Orthodontic technician of all time, in 2012. He has worked for some of the pioneers in the orthodontic and sleep dentistry fields. Gergen and his father John Gergen began Gergen Orthodontic labs in 1984 and have grown it into one of the most respected labs in the country. One of his proudest achievements is receiving The National Leadership award for Arizona Small Businessman of the Year in 2004. David is the Dental Director of the American Sleep and Breathing Academy and he has also taken a spot at Tufts University teaching seminars for the Continuing-Ed program on Dental Sleep Medicine.

 

 

David Gergen CDT

David Gergen CDT

David Gergen, CDT and President of Pro Player Health Alliance, has been a nationally respected dental lab technician for over 25 years. He received the award for “The Finest Orthodontic Technician in the Country” given by Columbus Dental in 1986. He also has been appointed Executive Director of the American Sleep and Breathing Academy Dental Division, a national interdisciplinary academy dedicated to sleep training and education with over 60,000 members. David rolled out of bed on December 4, 1982 and had his career “ah ha” moment. He knew he was going to be an orthodontic technician and he knew he was going to help people all over the country to help treat their sleep disorders in partnership with their dentists. He has worked for some of the pioneers in the orthodontic and sleep dentistry fields. He was the personal technician for the likes of Dr. Robert Ricketts, Dr. Ronald Roth, Dr. A. Paul Serrano, Dr. Clark Jones, Dr. Harold Gelb, Dr. Joseph R. Cohen, Dr. Rodney Willey, Dr. Allan Bernstein, and Dr. Thien Pham. One of his proudest achievements is receiving The National Leadership award for Arizona Small Businessman of the Year in 2004.

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IS A DEDICATED SLEEP PRACTICE RIGHT FOR YOU? Part 2 – ‘Building an Alliance’

Sleep Apnea Dentistry is perhaps the fastest growing part of my life. In my career I have always associated with the best dentists in the country. In my travels I have heard one question over and over again “Is a dedicated sleep practice right for me?”. The other question is “How will I know when to make the jump to a sleep only practice?”. This is the second installment of a 5 part series.

I asked Dr. Willey to write up his journey in sleep medicine, from the early days of training with Dental Sleep Medicine Pioneer and Legend Dr. Ed Spiegel. Being the person Dr. Willey is, days later I received a call from him, he said ” David I want to tell a five part history from the being leading up to my lecture in Scottsdale” from the very beginning. He told me he could do it in a five part series on his personal journey, here is part one. Remember at the American Sleep and Breathing Academy Dental meeting in Scottsdale AZ April 10-11 www.asbadental.com he is going to explain how he built the largest dental sleep practice in the United States, 2.5 million a year and 106 appliances in a single month.

IS A DEDICATED SLEEP PRACTICE RIGHT FOR YOU?

Part 2 – ‘Building an Alliance’

 

I finally had an opportunity to meet him. Recognizing the connection between my practice of obstructive sleep apnea and his practice of Ears, Nose and Throat, Dr. Holland was someone with whom I wanted to build an alliance.  Our office had made numerous calls in an attempt to set up a meeting and finally, we were in! Our conversation went well, both of us realizing that our philosophy for treating patients were symbiotic. As I left his office, I couldn’t help but think, “The real test will be IF he refers any of his patients to me.” As the months went by, he sent many referrals to me and soon became one of my largest referral sources and continues to this day.

The reason for his referrals had little to do with my reputation, location or credentials. It had everything to do with his perception that I was a sleep specialist (though I could never claim this title) because I

Rod Willey DDS America's most successful Sleep Apnea Dentist
Rod Willey DDS America’s most successful Sleep Apnea Dentist

limited my practice to OSA and TMD.  And, because I was practicing in a medical model just like he was. The medical model was key, meaning that I accept most all medical insurance and Medicare.

Many dentists are interested in providing sleep and/or TMD appliances to their patients, but the amount of work to get payment for these services seems overwhelming, even with software specifically designed for dental sleep medicine.

Jumping into the medical world can seem easy at first glace. It’s just a different claim form, right? Wrong. Most doctors aren’t aware of the risks of not asking the right questions on the pre-verification phone call and having all the necessary documentation on file. For instance, a dentist can bill a claim for the E0486 (OSA appliance) to Medicare and may see an immediate payment without records ever being requested. The issues come when Medicare decides to do an audit, which is guaranteed to happen.  If all documentation is not in complete order prior to impressions being taken, Medicare will ask for the money back and require it in a lump sum.   There could also be fines for non-compliance as a Medicare provider.  As you are well aware, this can completely bankrupt a practice.

I personally experienced a Medicare set back when I first began.  Our office staff had been trained that the x-ray we were taking on all our patients would be covered by Medicare.  When we started receiving denials for these x-rays, and realized that Medicare would not pay due to our provider type, we had to write off all charges.  As a Mediare provider, it is our responsibility to know what will be covered and what is not a covered procedure.  Fortunately our practice was in the beginning stage and it was early enough that my set back was minimal and I was able to appreciate a hard lesson well learned.

Medicare requires that all participating physicians convert to Electronic Health Records by 2015. A monetary penalty will be assessed if not fully in compliance. Certified software specific to dental sleep medicine is a must. In order to bill an evaluation and management procedure code, certain criteria must be met. Each visit must be evaluated prior to coding. This is important to prevent a Medicare trigger resulting in an audit. I found that audits are not only time consuming but drastically slows down payment flow.

Calling an insurance company for a pre-verification of benefits shouldn’t take a scientist.  Unfortunately, depending on the question, the representative interpreting the information, and the way the question is asked, wrong information can be given resulting in unhappy patients and a loss of money for the provider. Even if a code is “billable,” it may end up being denied.  I am thankful to have a dedicated billing department who understands the pre-verification process and the requirements necessary for maximum insurance reimbursement.

Being a Medicare provider carries much responsibility. When auditing records, Medicare can look into ANY patient, not just Medicare patients. What you do for one, you must do for all. Guidelines on insurance fraud, professional courtesy, and write offs are closely monitored. Medicare, Medicaid, and Tricare are all government agencies and any penalties or charges are a federal matter.

Another factor in building an alliance with specialist in the medical world is providing them with a sample of the appliance you are providing for patients.  I found that if I hand them an actual appliance they will recognize the difference between what we offer and what the local Walgreens and CVS stores offer over the counter.  When I provide them with a Gergen’s Lab appliance, it is impressive and professionally packaged.  Month after month I have the privilege of seeing 35-50 OSA/TMD patients every day, it is imperative that I can depend on my lab to ensure my reputation with my alliances is secure.

David Gergen CDT
David Gergen CDT

 

David Gergen CDT opened his family-owned Gergen’s Orthodontic Lab in Phoenix, AZ in 1986 and now employees over 80 people. David Gergen has been a nationally respected dental lab technician for over 25 years. He received the award for “The Finest Orthodontic Technician in the Country” given by Columbus Dental in 1986. He also received a lifetime achievement award by Dr Harold Gelb Academy as Americas greatest Orthodontic technician of all time, in 2012. He has worked for some of the pioneers in the orthodontic and sleep dentistry fields. Gergen and his father John Gergen began Gergen Orthodontic labs in 1984 and have grown it into one of the most respected labs in the country. One of his proudest achievements is receiving The National Leadership award for Arizona Small Businessman of the Year in 2004. David is the Dental Director of the American Sleep and Breathing Academy and he has also taken a spot at Tufts University teaching seminars for the Continuing-Ed program on Dental Sleep Medicine.

 

 

David Gergen CDT

David Gergen CDT

David Gergen, CDT and President of Pro Player Health Alliance, has been a nationally respected dental lab technician for over 25 years. He received the award for “The Finest Orthodontic Technician in the Country” given by Columbus Dental in 1986. He also has been appointed Executive Director of the American Sleep and Breathing Academy Dental Division, a national interdisciplinary academy dedicated to sleep training and education with over 60,000 members. David rolled out of bed on December 4, 1982 and had his career “ah ha” moment. He knew he was going to be an orthodontic technician and he knew he was going to help people all over the country to help treat their sleep disorders in partnership with their dentists. He has worked for some of the pioneers in the orthodontic and sleep dentistry fields. He was the personal technician for the likes of Dr. Robert Ricketts, Dr. Ronald Roth, Dr. A. Paul Serrano, Dr. Clark Jones, Dr. Harold Gelb, Dr. Joseph R. Cohen, Dr. Rodney Willey, Dr. Allan Bernstein, and Dr. Thien Pham. One of his proudest achievements is receiving The National Leadership award for Arizona Small Businessman of the Year in 2004.

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“Is A Dedicated Sleep Apnea Practice Right For Me?”

Sleep Apnea Dentistry is perhaps the fastest growing part of my life. In my career I have always associated with the best dentists in the country. In my travels I have heard one question over and over again “Is a dedicated sleep practice right for me?”. The other question is “How will I know when to make the jump to a sleep only practice?”.

I asked Dr. Willey to write up his journey in sleep medicine, from the early days of training with Dental Sleep Medicine Pioneer and Legend Dr. Ed Spiegel. Dr. Willey let me interview him on his success and that is what he will be speaking on at the American Sleep and Breathing Academy Dental meeting in Scottsdale AZ April 10-11 www.asbadental.com . Being the person Dr. Willey is days later I received a call from him, he said ” David I want to tell a five part history from the being leading up to my lecture in Scottsdale” from the very beginning. He told me he could do it in a five part series on his personal journey, here is part one. Remember at the American Sleep and Breathing Academy Dental meeting in Scottsdale AZ April 10-11 www.asbadental.com he is going to explain how he built the largest dental sleep practice in the United States, 2.5 million a year and 106 appliances in a single month.

 

 

If I knew then…  

 

“And what do you do for a living Joe?” “Purchasing agent for recreational pharmaceuticals” he replied with a wink and an unforgettable grin. Joe was a police officer and loved his work, and he never hesitated to share a good story of their newest hit on the streets.  I had the privilege of working with Joe’s wife, Sarah, for 22 years, she was a powerhouse assistant and though patients might miss a chance

America's most successful Sleep Apnea Dentist
America’s most successful Sleep Apnea Dentist

to see me, they never missed a chance to see Sarah!

I wish I could say she was on top of her game every day, truth is, she wasn’t. She would come in with her hands wrapped around a cup of coffee as though it were her security blanket for the day. And then I would hear the same old same old, “Joe was snoring so bad last night, I hardly got a wink.” Following her comments, someone would always have something to say to make everyone laugh. This went on week after week, year after year.

And then the dreaded phone call came, “Doc, can you come- Joe died in his sleep from an apparent heart attack.” Racing to their home, I arrived and joined the many other mourners.  Nothing made sense. Joe was a 40-year-old and in top physical shape.  Sure, there were a few thugs who didn’t care for his career – but there was no sign of struggle or foul play. Sarah was never the same, nor I was.

Several years later, I was taking a weekend course on “Sleep Apnea.”  And the pieces began to come together, all I could think of was Joe. I begin my search into dental sleep medicine with a determination to learn everything I possibly could and it wasn’t long until I knew that had I known then what I know now, Joe would most likely still be with us. From that moment on, dentistry changed for me. I began seeing my role differently and it wasn’t long until I was weaving sleep appliances in-between general dentistry and I always had a ‘win.’ Using Gergen’s Orthodontic Lab my cases were perfect, and that’s exactly what I was looking for.

I began experiencing a new fulfillment and I wanted more. Several patients that I had done a CBVT and radiologist read on were diagnosed with life threatening situations and their physicians called me to commend the find. Along the way a new group of challenges began to surface. I would look up to see my hygienist tapping her foot in the entrance of a treatment room, reminding me that I was spending too much time with ‘the sleep patient’ and it was sabotaging her schedule.  Though being a multi-tasker was a natural for me, I was struggling to keep it all flowing – perio, implants, pros, cosmetics and … Sleep. The sleep patients needed much more time and focus. And I had to choose between changing a life and saving a life. So I chose. In a very short period of time, I sold my dental practice and began a dedicated sleep practice. This is what I found:

  1. Physicians looked at me differently – I was no longer a dentist to them but a sleep specialist. (Though I could never claim this title)
  2. In a dedicated sleep practice, I didn’t miss a single OSA or TMD diagnosis because that’s all I did.
  3. Working within the medical model and accepting medical insurance is challenging but necessary.
  4. Undiagnosed sleep apnea was all around me, and I realized there are a lot of “Joe’s” that needed my services.
David Gergen CDT

David Gergen CDT

David Gergen, CDT and President of Pro Player Health Alliance, has been a nationally respected dental lab technician for over 25 years. He received the award for “The Finest Orthodontic Technician in the Country” given by Columbus Dental in 1986. He also has been appointed Executive Director of the American Sleep and Breathing Academy Dental Division, a national interdisciplinary academy dedicated to sleep training and education with over 60,000 members. David rolled out of bed on December 4, 1982 and had his career “ah ha” moment. He knew he was going to be an orthodontic technician and he knew he was going to help people all over the country to help treat their sleep disorders in partnership with their dentists. He has worked for some of the pioneers in the orthodontic and sleep dentistry fields. He was the personal technician for the likes of Dr. Robert Ricketts, Dr. Ronald Roth, Dr. A. Paul Serrano, Dr. Clark Jones, Dr. Harold Gelb, Dr. Joseph R. Cohen, Dr. Rodney Willey, Dr. Allan Bernstein, and Dr. Thien Pham. One of his proudest achievements is receiving The National Leadership award for Arizona Small Businessman of the Year in 2004.

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“Dr. Willey Wasn’t Getting Paid by Medicare And Now He Is” Success Story from the Trenches of Sleep Apnea Dentistry

Today, Dr. Willey is the most successful stand-alone sleep practice in the United States.

 

It isn’t always pleasant or easy to speak of one’s missteps.  A hallmark of dentistry is “getting it right”  the first time and every time.  Key to this commitment is a business model that sees 96-99% reimbursement  of billed fees from dental insurance, and an EBITDA that reflects the profits they’ve earned .

Dr Rod Willey America's most successful Sleep Apnea Dentist
Dr Rod Willey America’s most successful Sleep Apnea Dentist

What if the dentists weren’t getting paid?  What if they did the work, paid the staff, paid the lab bill and did the treatment without paying themselves? How long could they hold on? More often than not this is the story we hear from dentists who start billing medical insurance. Here’s Dr. Rod Willey’s story:

 

  1. WILLEY WASN’T GETTING PAID . . .

 

Every weekend event, online course and extra training Dr. Rod Willey attended prepared him for being a dentist who exclusively treated sleep apnea and facial pain.  When he was ready to make the final transition to a dedicated sleep practice, he brought in one of the ‘best’ trainers and consultants in the field, to his practice for a month of training, on three different occasions. Dr. Willey wanted to make certain everything was done exceptionally well by his hand and that his staff would not be left to wing it. Training was key and he paid the price for every minute of it.

Continue reading “Dr. Willey Wasn’t Getting Paid by Medicare And Now He Is” Success Story from the Trenches of Sleep Apnea Dentistry

David Gergen CDT

David Gergen CDT

David Gergen, CDT and President of Pro Player Health Alliance, has been a nationally respected dental lab technician for over 25 years. He received the award for “The Finest Orthodontic Technician in the Country” given by Columbus Dental in 1986. He also has been appointed Executive Director of the American Sleep and Breathing Academy Dental Division, a national interdisciplinary academy dedicated to sleep training and education with over 60,000 members. David rolled out of bed on December 4, 1982 and had his career “ah ha” moment. He knew he was going to be an orthodontic technician and he knew he was going to help people all over the country to help treat their sleep disorders in partnership with their dentists. He has worked for some of the pioneers in the orthodontic and sleep dentistry fields. He was the personal technician for the likes of Dr. Robert Ricketts, Dr. Ronald Roth, Dr. A. Paul Serrano, Dr. Clark Jones, Dr. Harold Gelb, Dr. Joseph R. Cohen, Dr. Rodney Willey, Dr. Allan Bernstein, and Dr. Thien Pham. One of his proudest achievements is receiving The National Leadership award for Arizona Small Businessman of the Year in 2004.

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Apnea and Sedation: A Potentially Dangerous Mix

Sleep apnea is on the rise and health professionals must implement a perioperative and periprocedure sleep apnea management program to reduce patient risk. 2

Mechanics of Sleep Apnea
Upper airway collapse is worsened during the perioperative and periprocedural care of a patient, especially if they receive premedication, general anesthesia, anxiolytics, antiemetics, and opioid analgesia.1,2,4,5  The result of decreased pharyngeal tone is reduced ventilation and oxygenation, causing hypoxia and hypercapnia, which inhibits the arousal response associated with each apnea incident of apnea. Airway obstructions also strain heart and lung function.

Premedication with drugs such as benzodiazepines has muscle relaxing effects on the upper airway musculature, causing a reduction of the posterior pharyngeal airway. The result is increased risk for hypoventilation, hypercapnia, and hypoxemia necessitating monitoring of oxygenation and ventilation.

There is considerable risk associated with premedications for procedures done outside the operating room, because we often underestimate the need for monitoring cardiovascular changes in these patients.  Capnography is a non-invasive alternative to ABGs and detects real time changes in carbon dioxide. Additionally, patients receive outpatient procedures and are sent home to recover shortly after procedure.  
Determining readiness for discharge requires defining risk factors for sleep apnea or sleep deprivation.  Routinely assessing discharge criteria will reduce the risk for problems at home.

On an intra-operative basis, these patients frequently have more difficult intubations and extubations.   They have a greater chance for adverse events due to hypoxemia, high or low blood pressure, cardiac arrythmias and aspiration pneumonias, as seen in the post anesthesia recovery unit (PACU). Discharge delays in the PACU are more likely due to an inability to maintain oxygenation at desirable levels for discharge, resulting in increased clinical care for nurses, anesthesiologists, and respiratory therapists.

Due to the risk for cardiopulmonary arrest, patients often require a discharge from PACU to a higher level of care for more exhaustive monitoring of their ventilation and increased sedation that can include telemetry, observation care for 7 hours or overnight, and even intensive care.1,2,5

Sleep patterns are changed significantly in patients recovering in a critical care unit. They have frequent interruptions that will worsen the effects of sleep deprivation, increasing the impact on sleep-disordered breathing. Treatment with positive air pressure will improve the outcome of patients with cardiac and respiratory co-morbidities, and the implications of this are significant, because sleep-disordered breathing is such a common (frequently untreated and undiagnosed) chronic disease of middle-aged adults.5

No Time to Relax
Anesthetics, analgesic, and sedative drugs produce increased muscle relaxation of the throat and tongue, and in someone at risk for sleep apnea, may create an airway blockage. When administering anesthetics, the surgeon anesthesiologist may need to alter the type and dosages of medications received to protect the breathing responses.  Post surgical pain management may also require adjustment to prevent diminished breathing. As a result, narcotic pain medication or sedation will be balanced to prevent respiratory depression.

Surgery of the upper abdomen, breast, chest, or upper airway can complicate matters for patients at risk for sleep apnea by causing increased respiratory discomfort. Respiration is shallow with these surgical procedures, and increased pain adds to this discomfort when trying to breath.

When being cared for in a supine position, added risk occurs from the relaxation of the muscles in the posterior airway. Unless contraindicated, the head of the bed should be elevated 20-30 degrees to lessen some of the force placed on the posterior airway.

Positive air pressure may be required to support breathing after surgery or after a procedure requiring sedation or pain medication, especially if depressed respiration due to decreased ventilation becomes a concern.

Deep Sleep Suffers
Patients at risk for sleep apnea experience less time in the deep levels of sleep, reducing the body’s natural capacity for healing and pain control. As a consequence, these processes work less effectively.

The states of NREM (non-rapid eye movement) and REM (rapid eye movement) each perform a different function, and both are crucial to overall daytime effectiveness. Going to sleep is like descending a stairway.  As brain activity slows, we transition into NREM sleep until we reach deep sleep. When in deep sleep, pulse and respiratory slows, blood pressure drops, muscles relax, and growth hormone is released to facilitate physical healing, enhanced pain control, and physical rejuvenation.

About every hour and a half we come out of deep sleep into REM sleep, an active state of sleep.
REM sleep is crucial since our breathing, blood pressure, pulse rate, and blood flow to the brain all increase during this phase. During REM sleep, our peripheral muscles are atonic.

REM presents a challenge to sustain breathing, oxygenation, and cardiac stability in patients at risk for sleep apnea. Clinical functions all become more difficult to sustain because apneic events are longer during REM, oxygen desaturation is lower, and more cardiac arrhythmias are noted during REM sleep. Since the longest REM period occurs in the early morning hours between 4:00 – 6:00 AM, we need to closely monitor our patients during this time.

Every stage of the health care continuum that provides sedation should implement sedation-related apnea management guidelines. This program will reduce patient risk, reduce medical liabilities, and create additional sleep apnea patient disease management revenue streams for related health professionals. 7

Christopher VuSleep Advoacate
The author is a staff writer for
Sleep Diagnosis and Therapy

References
1.    den Herder C, Risks of general anaesthesia in people with obstructive sleep apnoea. BMJ 2004; 329:955-9.
2.    Estfan B, Respiratory function during parenteral opioid titration for cancer pain. Palliative Medicine. 2007; 21: 81-6.
3.    Feinsilver, SH, A sleeping giant:  sleep-disordered breathing in the coronary care unit. Chest 2005; 127: 4-5.
4.    Morgenthaler TI, Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome:  an update for 2007.  An American Academy of Sleep Medicine report.  Sleep. 2008 Jan 1; 31 (1): 141-7.
5.    Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea.  A report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea.  Anesthesiology 2006; 104:1081-93.
6.    Preventing and managing the impact of anesthesia awareness. Sentinel Event Alert Joint Commission on Accreditation of Healthcare Organizations October 6, 2004; Issue 32.

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