The Sky is falling: Difficult Patient’s in our Labs Gregory Miller Coordinator Sleep Center Ascension, St Mary’s of Michigan

You will learn at least 1 thing by the end of this talk. Goals

Disclosure Nothing to disclose Remember that your labs policies and protocols trump anything in this talk Disclosure

Home Sleep Apnea Testing HST not new 1988 Merimed (4 channel airflow, effort, oximetry and heartt rate, 1992 Edent Trace II plus could do pH (5 channel), 1990 NightWatch Level 3: 4 parameters 1993 Coppola and Lawee found that unattended 4 channel recoring can be an accurate tool in the diagnosis of moderate to severe sleep apnea 2005 AASM came out with practice parameters (co-morbidities) pulse ox not recommended 2007 AASM recognizes HST 2008 CMS reimbursement for HST Home Sleep Apnea Testing

Denial Anger Bargain Depression ACCEPTANCE Home Sleep Testing

CPAP Failure Why did they fail? Mask comfort? Pressure? Humidity? Lack of education CPAP Failure

VPAP, BiPAP When should it be used? Backup rate? BiLevel

Obstructive Lung Disease Asthma COPD Bronchitis Obstructive Lung Disease

Restrictive Lung Disease Cystic Fibrosis Restrictive Lung Disease

Neuromuscular Disease MS ALS Parkinson’s Quadraplegic Neuromuscular Disease

Alveolar Hypoventilation Central Alveolar hypoventilation “Ondines Curse” Obesity Hypoventilation Syndrome “Pickwickian Syndrom” Alveolar Hypoventilation

Cheyne Stokes Breathing Complex Sleep Apnea? Central Sleep Apnea

Other Types of Difficult patient’s Obnoxious Other Types of Difficult patient’s