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How Long Does a CPAP Prescription Last?

Wednesday March 26, 2014

CPAP machines

If you use continuous positive airway pressure (CPAP) or bilevel to treat your sleep apnea, you may wonder: how long does a CPAP prescription last? Though the answer may vary somewhat based on your insurance, there are a few rules of thumb that can be followed.

In most cases, the prescription your sleep specialist gives you for CPAP and the associated equipment will be good for 1 year from the time it is issued. This ensures that you are regularly checking in with your physician to ensure that your treatment is optimized. Your doctor can help you address any problems and update you on new masks, comfort features, or other developments. This face-to-face encounter also allows your medical history and physical examination to be reviewed. The prescription will allow you to replace your supplies as often as you should.

Medicare patients are required to have these visits every 6 months. Therefore, the prescription for equipment only lasts for this period.

The requirements may vary with some insurers, and your durable medical equipment provider should be able to inform you of any special circumstances that may apply to you.

Keep in mind that most CPAP machines are completely replaced at 5-year intervals. Therefore, if you are using an older machine, you may be eligible for a full upgrade of your unit.

All CPAP supplies are considered to be medical equipment and this is why they are controlled with the issuance of a prescription from a sleep specialist. If you are due to get new supplies, but your prescription has expired, you should start by checking in with your doctor.

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Why Periodic Limb Movements Are Not Restless Legs Syndrome

Saturday March 22, 2014

This is an issue that confuses patients and sleep specialists alike: what is the difference between periodic limb movements of sleep and restless legs syndrome? And why does it matter?

Movements of the legs at night can disturb sleep and lead to insomnia. However, not all movements are alike. In order to understand the difference between overlapping disorders, it is important to get back to the basics.

Restless legs syndrome (RLS) is a condition that leads to discomfort in the legs and may even be associated with intentional, conscious movements. It consists of four key features:

  • An urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs.
  • The urge to move or unpleasant sensations begin or worsen during periods of rest or inactivity such as lying or sitting.
  • Sensations that are relieved by movement, such as walking or stretching, as long as the activity continues.
  • Sensations that are worse during the evening or night.

RLS is a clinical diagnosis. It is based on the symptoms that a patient complains of and no testing is required. The prevalence of RLS is estimated to be 5% to 10% of people. It is often treated with iron replacement and prescription medications.

Interestingly, RLS is commonly associated with unconscious periodic limb movements of sleep (PLMS). This is a separate diagnosis, and one that is made based on the results of a polysomnogram. When a sleep study occurs, wires are placed on the front of the legs that measure movements. If leg movements occur frequently or intensely, they may disturb sleep. In general, the PLM index is considered to be abnormal when more than 15 events occur per hour in adults.

PLMS can occur secondary to other sleep disorders. For instance, someone with sleep apnea may kick his or her legs as part of opening the airway to resume breathing. Moreover, no matter the trigger, these movements are not thought to contribute to significant sleep disruption in isolation. Therefore, they are usually not treated when they are observed on a sleep study without any corresponding RLS symptoms.

In summary, RLS is a condition that is based on symptoms and not testing. PLMS is observed on a test, and may not have associated RLS symptoms because it can also occur in other disorders like sleep apnea. Most sleep specialists do not treat PLMS with medications for RLS if no RLS symptoms are reported. If the movements are disruptive to a bed partner, treatments may be pursued to quiet the movements at night.

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Sleep Apnea and the Effects on Your Health

Friday March 21, 2014

Sleep is not always a benign state. Snoring may not be harmless. In fact, a related condition that affects breathing during sleep may have important consequences. This disorder, sleep apnea, can have significant effects on your overall health.

There are certain symptoms and signs associated with obstructive sleep apnea that can affect day-to-day life. Excessive daytime sleepiness, mood complaints like anxiety or depression, or difficulty with thinking may undermine concentration or memory. However, untreated sleep apnea can have other unwanted side effects.

Sleep apnea may increase blood pressure, lead to insulin resistance and diabetes, worsen heart failure, provoke heart arrhythmias like atrial fibrillation, and even lead to heart attack, stroke, and sudden death. These risks occur over the long term. Just like one cigarette likely won't kill you, but smoking over many years just might, sleep apnea may increase your health risks over decades of exposure.

Review some information about how sleep apnea may contribute to heart health problems, stroke, sudden death, and even have specific consequences in children.

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Battling the Bed Bugs

Thursday March 20, 2014

Photo of actual bed bugs

It is a perennial headline that appears in the news: "Bed Bugs Are Back!" You may wonder about these little critters and why they seem to bedevil us everywhere these days. Take a moment to review some information on what bed bugs are, what harm they may (or may not) be, the symptoms associated with bed bug exposure, and the treatment options available if you face an infestation. You don't have to let these creepy, crawly nuisances bother you. Sleep tight - and don't let the bed bugs bite!

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Fellowship Training in Sleep Medicine

Saturday March 15, 2014

What does it mean for a physician to be fellowship-trained in sleep medicine? If you are a patient, why should you care? Learn how fellowship training may enhance your experience at your next doctor's visit to treat your sleep disorder.

Medical training is really confusing. Even while I was in college, working in a sleep clinic over a summer and completing applications to medical school, I didn't really understand what all the titles meant. There is a litany: intern, resident, fellow, attending, house staff, and a smattering of others. In order to sort out the vocabulary, it can be helpful to understand the typical training process of doctors in the U.S. (with the understanding that it can be even more complicated abroad - for example, the title Mr. is higher than Dr. among surgeons in England).

After completing a 4-year degree at a college or university, medical school begins. This also typically lasts 4 years, usually with 2 years of classroom education followed by 2 years of clinical training on the hospital wards. This may less commonly be lengthened by time spent in research or even obtaining master's degrees in public health (MPH) or business administration (MBA).

After graduation from medical school, post-graduate training begins. Depending on the primary field or specialty selected, the length of this training varies. For example, doctors who practice internal medicine, pediatrics, or emergency medicine are trained for 3 additional years. Those who select obstetrics and gynecology, neurology, or psychiatry are trained for 4 years. Some internal medicine doctors undergo additional training to become pulmonologists, cardiologists, allergists, or gastroenterologists. Surgical training may often last 5, 6, or even more years. This period of training always starts with an intern year and is followed by additional years of residency in which the trainee is referred to as a resident. Then, graduation occurs with the opportunity to start practicing medicine, but some choose to continue in fellowship training.

Fellowship training is sub-specialty training in which the physician learns a specific set of knowledge or skills. These opportunities are dependent on the prior training that occurs. For example, someone who is interested in a sleep medicine fellowship often has previously trained in pulmonary medicine, neurology, psychiatry, or internal medicine. Sleep medicine fellowships usually last 1 year, but a few programs in the country at Harvard and Johns Hopkins include a research year and last for 2 years.

Why would you want a doctor who has fellowship training in sleep medicine? There are a handful of credentials that can be important to determine the expertise and skill of your medical provider. Board certification can be one of these. This is an examination administrated by a medical board that, after verifying the necessary training has been completed, tests the person's knowledge base. Interestingly, many board-certified sleep specialists passed the examination but never underwent fellowship training. This might mean that they are good at taking tests, but may not know as much as they should about sleep medicine. This practice was changed in the past few years and now all doctors who wish to become board-certified in sleep medicine must complete sleep medicine fellowship training.

Having completed my fellowship training at the premier program at Stanford University, I can attest to the value this education and training has added to my practice of medicine. I am better able to treat the myriad sleep disorders and apply the proper evaluations and treatments to help my patients sleep better. There are some 7,500 board-certified sleep medicine specialists in the United States and, unfortunately, many of them do not provide the quality of care that I would like my patients to have. They have not received the training that could aid their practice of sleep medicine. Many work in this specialty because of its profitability with little interest in, expertise of, or passion for the field itself.

In the coming years, as older providers retire, more sleep specialists will be fellowship-trained. In the meanwhile, you should review your doctor's credentials online to ensure that they have the sleep medicine fellowship training that you should expect to get the best treatment of your sleep disorder possible.

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Board-certified Sleep Specialists Provide Better Sleep Apnea Care

Friday March 14, 2014

New research in the March 15 issue of the Journal of Clinical Sleep Medicine suggests that patients with obstructive sleep apnea who are treated by board-certified sleep specialists have improved adherence to therapy.

The most common treatment of sleep apnea is continuous positive airway pressure (CPAP) therapy, which remains the gold standard to cure the condition. This treatment can sometimes require accommodations to make it more comfortable, however. If early interventions are not made when problems arise, patients are less likely to continue using it.

The study, "A Multicenter Prospective Comparative Effectiveness Study of the Effect of Physician Certification and Center Accreditation on Patient-Centered Outcomes in Obstructive Sleep Apnea," assessed 502 patients with sleep apnea at four sleep centers. Participants received an objective diagnostic evaluation using overnight polysomnography and completed validated questionnaires. Objective CPAP therapy adherence was measured 3 months after therapy initiation.

The findings demonstrated that sleep apnea patients who are cared for by board-certified physicians and accredited sleep centers were two times more likely to be compliant. Patient satisfaction and timeliness of care were also associated with these factors.

"We have demonstrated under real-world conditions that sleep center accreditation and sleep medicine board certification are important determinants of patient-centered quality metrics such as adherence to PAP therapy, patient satisfaction, patient education and timeliness of care delivery," said lead author and principal investigator Dr. Sairam Parthasarathy, associate professor of medicine at the University of Arizona in Tucson, Ariz. "These results suggest that health policy decisions should be directed toward care pathways involving accredited facilities and board-certified physicians."

The American Academy of Sleep Medicine (AASM) is a professional organization of sleep specialists. "Board certified sleep medicine physicians and the team of health care professionals at accredited sleep centers have the specialized training and expertise to provide high quality, patient-centered care for people with a sleep illness," said AASM President Dr. M. Safwan Badr.

There are estimated to be about 7,500 board-certified sleep specialists in the U.S., most of whom are medical doctors with other specialty training. The certification was initially available to providers who passed an examination, but now sleep specialists are required to complete fellowship training to improve their knowledge and skills in sleep medicine before sitting for the exam. Accredited sleep centers can be searched for online at the AASM.

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New Edition of International Classification of Sleep Disorders Available

Friday March 14, 2014

The American Academy of Sleep Medicine (AASM) has released the 3rd edition of the International Classification of Sleep Disorders (ICSD-3) as an eBook in its resource library.

This authoritative text is used by clinicians and researchers alike for the diagnosis and treatment of sleep disorders. The previous edition was published in 2005. It is the collective opinion of sleep experts from the AASM who determine the names, symptoms, and diagnostic features of the most common sleep problems. These disorders are divided into six broad categories that include:

The ICSD-3 was updated in 2014 and includes important content revisions. In particular, the sections on insomnia and narcolepsy have been significantly revised. The book includes diagnostic codes that correspond to both the ICD-9 and upcoming ICD-10, used for billing purposes in a clinic setting.

The book is available to members of the AASM for $60 and to non-members for $100. It is not yet available in a print edition.

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Why It's Important to Bring Your CPAP to See Your Doctor

Friday February 28, 2014

Pictured are the Respironics and ResMed CPAP machines.

If you use continuous positive airway pressure (CPAP) to treat your sleep apnea, you are likely quite familiar with the machine and its accompanying supplies. It may have a fixed place in your home next to your bed, but why might it be important to occasionally pack it up and bring it with you to see your doctor?

Whether you use CPAP, or other related treatments like bilevel, the machine is an integral part of your experience. Compliance to therapy is often dependent on having the right device, proper settings, and the related equipment to support your efforts. The supplies may include the mask interface, headgear, tubing (often heated), air filters, and even a chinstrap. These items can make or break your experience.

When you are just starting therapy, you may encounter specific problems. Perhaps the mask is not fitting properly. You may not know how to work all the bells and whistles of the machine. The humidifier and temperature settings may require some fine tuning. All of these issues can best be addressed by your sleep specialist or durable medical equipment provider, both with an expertise in managing these concerns.

As treatment continues, maintenance needs may also present themselves. The equipment may start to wear out and require replacement. There may be a funny noise that needs addressing. The humidifier may not be working as well as it once did. It is necessary to replace all the supplies on a regular basis. This requires a current prescription from your doctor, and this expires every 6 to 12 months. Moreover, your sleep specialist can help you to troubleshoot issues and point out equipment requiring replacement.

Therefore, whenever you go in to see your sleep doctor for routine follow up, it is best to bring your machine and equipment in as well. Don't forget the mask, tubing, and power cord. The doctor will download the usage data from the data card within the machine. Sometimes this card is corrupted, however, and by bringing in the machine the data stored on the device can be analyzed. If there are specific problems, the equipment can be inspected and the issues can be addressed. It is sometimes even helpful to have patients try on their masks or turn on the machine. In addition, if the settings need to be changed, this can be done easily in the office with the CPAP present.

Just like you wouldn't show up to your mechanic without your car, don't go to your sleep specialist without your CPAP machine and equipment. There are some providers who may not require you to bring everything in, but do it anyhow. This is the best way to address any issues that you might have with your therapy. You should see your sleep specialist at least once per year, and when you visit, always bring your CPAP.

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Refusing Weight Checks at Your Doctor Only Harms Your Health

Thursday February 27, 2014

An obese man sleeps near his fruit stand.

My office is across from the station we use in our clinic to measure vital signs. When I leave my door open, I can overhear patients interact with the medical assistant as they are checked in. I am shocked by the number of patients, usually women, who refuse to have their weight measured as part of the intake process. This may have serious consequences.

As one of my professors taught us in medical school, vital signs are just that: vital. They are extremely important and each and every one can tell us much about the state of a patient's health. These vital signs include blood pressure, heart rate, respiratory rate, blood oxygen level, height, and weight. In my office, we also measure neck size as it can have implications for the risk of sleep apnea. Doctors use this information to direct their questioning and, ultimately, the therapy meant to improve your health.

Refusing weight checks is unwise. When patients are overweight or obese, there is often a psychological stigma associated with this assessment. These individuals may feel like they are a failure. It may be associated with intense shame. It may feel better not to even think about it. This is not healthy.

Visiting the doctor's office is a chance to check on your weight, even to discuss ways to lose weight. Ideally, weight would be checked daily at home on a scale. This would allow a more immediate accountability to the prior day's eating and exercise habits. It also provides positive reinforcement when the weight is gradually lost. Ignoring your weight, shuttering it away, and refusing to acknowledge the problem simply reinforces denial and deferment.

Don't refuse the weight check at your next doctor's visit. Your doctor may overlook the omission, but your weight problem won't go away. You may feel better not knowing, but as it wears on your health, even your sleep, you'll regret ignoring this important part of your examination.

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Driving Under the Influence of Ambien

Wednesday February 26, 2014

In the trial of Kerry Kennedy, she recently disclosed in testimony her belief that she mistakenly took Ambien instead of her thyroid medication and that his contributed to an accident in 2012 in which she swerved and hit a tractor trailer. This raises important concerns about the effects of Ambien on driving, both when taken accidentally in the day or when its effects last into the morning.

Ambien is typically prescribed as a sleeping pill. It is sold under the generic name of zolpidem. It may come in an extended-release form called Ambien CR or as a lower dose to be taken in the middle of the night called Intermezzo. Once taken, users are advised to immediately go to bed. The reason for this becomes clear when considering how it affects the brain.

Ambien is a hypnotic medication. It modestly increases total sleep time compared to baseline. It has profound effects on awareness and memory, however. Therefore, while the drug is in your system, consciousness may be clouded and memory absent. This can lead to one of the more common side effects: parasomnias. Parasomnias are sleep behaviors which might include sleepwalking, sleep eating, and, yes, even sleep driving. These elaborate behaviors are possible when the part of the brain that controls movement remains awake while the areas controlling memory and consciousness are turned off.

This can clearly impact daytime function if the medication is taken unintentionally, as may have occurred in Ms. Kennedy's case. The nighttime effects may also persist into the early morning hours if the blood levels remain high. Therefore, last year the U.S. Food and Drug Administration (FDA) recommended that women take lower doses of Ambien and Ambien CR. It was observed that the higher doses compromised driving ability in women in the morning.

Depending on metabolism, which is based on body mass as well as kidney or liver function, men may be similarly affected. Therefore, it is recommended that the lowest effective dose of Ambien be used. In addition, these medications should not be used for extended periods of time, beyond about 2 weeks. Instead, cognitive behavioral therapy for insomnia (CBTI) may be a more effective solution for chronic insomnia.

If you are interested in learning ways to discontinue Ambien, you may start by speaking to your doctor who can provide a referral to a sleep specialist.

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