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

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

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

4. Home Sleep Apnea Testing
HST not new
1988 Merimed (4 channel airflow, effort, oximetry and heartt rate, Edent Trace II plus could do pH (5 channel), 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

5. Denial
Anger
Bargain
Depression
ACCEPTANCE
Home Sleep Testing

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

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

8. Obstructive Lung Disease
Asthma
COPD
Bronchitis
Obstructive Lung Disease

9. Restrictive Lung Disease
Cystic Fibrosis
Restrictive Lung Disease

10. Neuromuscular DiseaseMS
ALS
Parkinson’s
Quadraplegic
Neuromuscular Disease

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

12. Cheyne Stokes Breathing
Complex Sleep Apnea?
Central Sleep Apnea

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