1. HOME OBSTRUCTIVE SLEEP APNEA MANAGEMENT IN THE USA AND ABROAD P. LYNN NICHOLS, M.D. DABSM,FCCP

2. MEDICAL DIRECTOR

3. Summitsleeptn.com

4. Financial disclosures I make a living as a pulmonologist and sleep physician I make a living as a pulmonologist and sleep physician No large medical company has ever offered me any money, but I am open to the idea No large medical company has ever offered me any money, but I am open to the idea

5. WHAT IS THE NAME OF THIS PROCEDURE, ANYWAY? Home Sleep Testing (HST) Home Sleep Testing (HST) Out of Center Sleep Testing (OCST) Out of Center Sleep Testing (OCST) Portable Monitoring (PM) Portable Monitoring (PM) Limited Channel Testing (LCT) Limited Channel Testing (LCT) *proposed- Home Obstructive Sleep Apnea Management (HOSAM) *proposed- Home Obstructive Sleep Apnea Management (HOSAM)

6. GOALS Scientific rationale for HST Scientific rationale for HST HST experience in socialized medicine (New Zealand) HST experience in socialized medicine (New Zealand) HST four year experience in private US Sleep Center HST four year experience in private US Sleep Center Where is sleep disorder management headed in the US? Where is sleep disorder management headed in the US?

7. SCIENTIFIC RATIONALE FOR HST/HOSAM

17. NEW ZEALAND

21. HAKA

24. Design and implement an obstructive sleep apnea diagnostic and treatment program for 150,000 rural New Zealanders The Challenge Design and implement an obstructive sleep apnea diagnostic and treatment program for 150,000 rural New Zealanders

26. NZ$100,000 SLEEP PROGRAM

27. OTHER RESOURCES One respiratory therapist dedicated to pulmonary function lab and sleep program (I had to hire) One respiratory therapist dedicated to pulmonary function lab and sleep program (I had to hire) 4 small hospitals/clinics with nursing staff 4 small hospitals/clinics with nursing staff Chartered airplane (my favorite) Chartered airplane (my favorite) Support of Auckland sleep lab Support of Auckland sleep lab

28. MORNING COMMUTE

29. IT’S ALL ABOUT THE ALGORITHM GP referral letter to Respiratory Consultant GP referral letter to Respiratory Consultant Home sleep test with follow up at next respiratory clinic with initiation of Auto CPAP Home sleep test with follow up at next respiratory clinic with initiation of Auto CPAP Auto CPAP download next CPAP clinic and placed on cheaper fixed CPAP unit Auto CPAP download next CPAP clinic and placed on cheaper fixed CPAP unit CPAP clinic follow ups with RT CPAP clinic follow ups with RT Referral to Auckland if necessary Referral to Auckland if necessary

30. OUTCOME AT ONE YEAR Around 70% of patients could be managed without in-lab study initially Around 70% of patients could be managed without in-lab study initially Recruited a respiratory consultant from South Africa to continue the programs Recruited a respiratory consultant from South Africa to continue the programs

31. Home Sleep Testing Technical Perspective Nicole Line, RPSGT, RST,PSGP Clinical Director

32. DISCLAIMER The following slides are opinions derived from our experiences at Summit Sleep Services and are in no way representative of all Sleep Center situations.

33. As techs, our first reaction to HST…….

35. Embletta Gold by Embla

36. Features: Easy application with color coded sensors Easy application with color coded sensors Pre-program multiple studies Pre-program multiple studies Rechargeable battery Rechargeable battery Internal position sensor Internal position sensor Ability to record 12 channels Ability to record 12 channels

37. Embletta Gold by Embla Limitations: Heavier unit Heavier unit Difficult for patients to apply themselves Difficult for patients to apply themselves Somewhat difficult to score Somewhat difficult to score

38. Nihon Kohden Nomad

39. Features: Integrates with NK system Integrates with NK system Auto starts with pulse signal or can be set to start at a designated time Auto starts with pulse signal or can be set to start at a designated time 2GB internal memory 2GB internal memory Uses 2 AA batteries Uses 2 AA batteries Has ability to monitor 12 channels: thermister, pressure transducer, snore, body position, SPO2, pleth, pulse, chest effort, abdominal effort, 2 limb channels and 1 DC output Has ability to monitor 12 channels: thermister, pressure transducer, snore, body position, SPO2, pleth, pulse, chest effort, abdominal effort, 2 limb channels and 1 DC output

40. Nihon Kohden Nomad Limitations: Larger/heavier than most units Larger/heavier than most units Higher price point Higher price point Costly to repair Costly to repair Difficult for patient to apply themselves Difficult for patient to apply themselves

41. SleepView by CleveMed

42. Features: Cloud based Cloud based Easy patient application Easy patient application Very light Very light Capable of recording 7 channels: Pulse oximetry, heart rate, respiratory effort, cannula based airflow, thermister based airflow, snore, and body position Capable of recording 7 channels: Pulse oximetry, heart rate, respiratory effort, cannula based airflow, thermister based airflow, snore, and body position Uses 1 AAA battery Uses 1 AAA battery All necessary study supplies included All necessary study supplies included 1 GB internal memory 1 GB internal memory

43. SleepView by CleveMed Limitations: Belt seemed to slip out of place during recording resulting in a sub- optimal signal Belt seemed to slip out of place during recording resulting in a sub- optimal signal Cumbersome log in/ log out process for downloading, scoring and interpreting in one location Cumbersome log in/ log out process for downloading, scoring and interpreting in one location

44. Apnea Link Plus by ResMed

45. Features: 4 channels: nasal flow (and snore), pulse, oxygen saturation, and respiratory effort 4 channels: nasal flow (and snore), pulse, oxygen saturation, and respiratory effort Lightweight Lightweight Easy patient application Easy patient application Uses 2 AA batteries Uses 2 AA batteries Ability to email report and recording Ability to email report and recording Cost effective Cost effective

46. Apnea Link Plus by ResMed Limitations: No body position sensor No body position sensor No numerical values when scoring desaturations No numerical values when scoring desaturations

48. SUMMIT HST ALGORITHM Sleep physician consult and HST ordered if appropriate HST interpreted Sleep clinic follow-up with initiation of auto-CPAP 4- 14 if indicated In-lab CPAP titration if auto-CPAP fails to resolve symptoms If HST nondiagnostic then either repeat HST or in-lab study ordered

49. HST INTERPRETATION TEMPLATE

50. WHERE IS SLEEP MEDICINE HEADED IN THE USA?

51. THANK YOU