Neil Freedman

Sleep apnea and commercial motor vehicle operators: statement from the joint Task Force of the American College of Chest Physicians, American College of Occupational and Environmental Medicine, and the National Sleep Foundation

M edical research supports the finding that obstructive sleep apnea (OSA) is a significant cause of motor vehicle crashes (MVCs) resulting in twoto sevenfold increased risk. Recent reports indicate OSA is present in a greater prevalence in operators of commercial motor vehicle (CMV) operators than in the general population. Although U.S. commercial drivers are required by federal statute to undergo medical qualification examinations at least every 2 years, the most recent OSA recommendations for medical examiners were prepared during a 1991 conference sponsored by the Federal Highway Administration (FHWA). Since then, the clinical diagnosis, evaluation, treatment, and follow-up criteria have changed significantly. Lacking current recommendations from the U.S. Department of Transportation (DOT), commercial driver medical examiners (CDMEs) must rely on outdated guidance and are thus forced to fill in the many existing gaps when evaluating CMV operators for this safety-sensitive type of work. In addition to causing difficulties for the medical examiner, the current guidelines, or lack thereof, foster an environment in which drivers who possibly have OSA are afraid to be evaluated because it might result in their removal from work. This set of circumstances may lead to the underrecognition of this condition and an increase in MVCs. From OccuMedix, Inc. (Dr Hartenbaum), Dresher, Pennsylvania; the Department of Medicine, Division of Pulmonary/Critical Care Medicine (Dr Collop), Johns Hopkins University, Baltimore, Maryland; the Department of Medicine, Divisions of Sleep Medicine and Pulmonary, Allergy & Critical Care Medicine (Dr Rosen), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; the Division of Pulmonary Critical Care and Sleep Medicine (Dr Phillips), University of Kentucky College of Medicine, Lexington, Kentucky; the Department of Medicine, Division of Respirology (Dr George), University of Western Ontario, and the Sleep Laboratory, London Health Sciences Centre, South Street Hospital, London, Ontario, Canada; the Department of Medicine, Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine (Dr Rowley), Wayne State University School of Medicine, Harper University Hospital, Detroit, Michigan; The Sleep and Behavior Medicine Institute and Pulmonary Physicians of the North Shore (Dr Freedman), Bannockburn, Illinois; Biobehavioral and Health Sciences Division (Dr Weaver), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; the Department of Medicine, Divisions of Sleep, Pulmonary and Critical Care Medicine (Dr Gurubhagavatula), University of Pennsylvania Medical Center, Philadelphia, Pennsylvania; the Department of Medicine, Director (Dr Strohl), Center for Sleep Disorders Research, Case Western Reserve University School of Medicine, Louis Stokes DVA Medical Center, Cleveland, Ohio; the IHC Health Services to Business (Dr Leaman), Intermountain WorkMed, Salt Lake City, Utah; and Arkansas Occupational Health (Dr Moffitt), Springdale, Arkansas; Alertness Solutions (Dr Rosekind), Cupertino, CA. Address correspondence to: Natalie Hartenbaum, MD, MPH, FACOEM, President and Chief Medical Officer, OccuMedix, Inc., P.O. Box 197, Dresher, PA 19025; E-mail: occumedix@comcast.net. Copyright

Diffusion lung capacity for carbon monoxide (DLCO) is an independent prognostic factor for long-term survival after curative lung resection for cancer.

We examined the early and late prognostic significance of DLCO and forced expiratory volume in 1 sec (FEV1) in patients who underwent surgical resection of lung cancer.

Altered Circadian Rhythmicity in Patients in the ICU

BACKGROUND Patients in the ICU are thought to have abnormal circadian rhythms, but quantitative data are lacking. METHODS To investigate circadian rhythms in the ICU, we studied core body temperatures over a 48-h period in 21 patients (59 ± 11 years of age; eight men and 13 women). RESULTS The circadian phase position for 17 of the 21 patients fell outside the published range associated with morningness/eveningness, which determines the normative range for variability among healthy normal subjects. In 10 patients, the circadian phase position fell earlier than the normative range; in seven patients, the circadian phase position fell later than the normative range. The mean ± SD of circadian displacement in either direction (advance or delay) was 4.44 ± 3.54 h. There was no significant day-to-day variation of the 24-h temperature profile within each patient. Stepwise linear regression was performed to determine if age, sex, APACHE (Acute Physiology and Chronic Health Evaluation) III score, or day in the ICU could predict the patient-specific magnitude of circadian displacement. The APACHE III score was found to be significantly predictive of circadian displacement. CONCLUSIONS The findings indicate that circadian rhythms are present but altered in patients in the ICU, with the degree of circadian abnormality correlating with severity of illness.

COUNTERPOINT: Does Laboratory Polysomnography Yield Better Outcomes Than Home Sleep Testing? No

[ 1 4 8 # 2 C H E S T AU G U S T 2 0 1 5 ] 7. Mulgrew AT , Fox N , Ayas NT , Ryan CF . Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study . Ann Intern Med . 2007 ; 146 ( 3 ): 157 166 . 8. Masa JF , Corral J , Pereira R , et al ; Spanish Sleep Network . Th erapeutic decision-making for sleep apnea and hypopnea syndrome using home respiratory polygraphy: a large multicentric study . Am J Respir Crit Care Med . 2011 ; 184 ( 8 ): 964 971 . 9. Masa JF , Corral J , Sanchez de Cos J , et al . Eff ectiveness of three sleep apnea management alternatives . Sleep . 2013 ; 36 ( 12 ): 1799 1807 . 10. Chervin RD , Murman DL , Malow BA , Totten V . Cost-utility of three approaches to the diagnosis of sleep apnea: polysomnography, home testing, and empirical therapy . Ann Intern Med . 1999 ; 130 ( 6 ): 496 505 . 11. Pietzsch JB , Garner A , Cipriano LE , Linehan JH . An integrated health-economic analysis of diagnostic and therapeutic strategies in the treatment of moderate-to-severe obstructive sleep apnea . Sleep . 2011 ; 34 ( 6 ): 695 709 . 12. Ayas NT , Pack A , Marra C . Th e demise of portable monitoring to diagnose OSA? Not so fast! Sleep . 2011 ; 34 ( 6 ): 691 692 . 13. El Shayeb M , Topfer LA , Stafi nski T , Pawluk L , Menon D . Diagnostic accuracy of level 3 portable sleep tests versus level 1 polysomnography for sleep-disordered breathing: a systematic review and meta-analysis . CMAJ . 2014 ; 186 ( 1 ): E25 E51 . 14. Mokhlesi B , Tulaimat A , Faibussowitsch I , Wang Y , Evans AT . Obesity hypoventilation syndrome: prevalence and predictors in patients with obstructive sleep apnea . Sleep Breath . 2007 ; 11 ( 2 ): 117 124 . 15. Chai-Coetzer CL , Antic NA , Rowland LS , et al . Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of life: a randomized trial . JAMA . 2013 ; 309 ( 10 ): 997 1004 . 16. Colten HR , Altevogt BM . Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem . Washington, DC : Th e National Academies Press ; 2006 . 17. Kuna ST , Shuttleworth D , Chi L , et al . Web-based access to positive airway pressure usage with or without an initial fi nancial incentive improves treatment use in patients with obstructive sleep apnea [published online ahead of print January 12, 2015]. Sleep .

Evolution in Reimbursement for Sleep Studies and Sleep Centers

Because of the rapid increase in the volume and costs of polysomnography and other sleep medicine diagnostic services, the Centers for Medicare & Medicaid Services (CMS) recently commissioned the Office of Inspector General (OIG) to review claims submitted for these services. The OIG found numerous cases of inappropriate payment for submitted claims and recommended significant changes in the CMS auditing process for polysomnography claims review. Additionally, a local Medicare Administrative Contractor released the most specific rules and regulations to date regarding billing and payment for sleep medicine services. These regulations specify covered diagnoses for submitted claims for both facility-based polysomnograms and unattended home sleep tests (HSTs) and list noncovered diagnoses that cannot be used to document medical necessity for such studies. The proposed rules specify minimum credentials for technologists performing polysomnograms and HSTs, mandate education prior to application of HST devices, demand a follow-up visit to discuss results after studies, and elaborate new requirements for physicians interpreting these studies. Providers of sleep medicine services must be prepared to provide documentation of diagnoses and indications when submitting claims for sleep services, and they can expect to be required to produce evidence of accreditation of the physicians and technologists providing services and the credentials of the sleep center. These changes will dramatically affect sleep medicine practitioners who order sleep studies and positive airway pressure therapies. Successful sleep medicine centers and sleep physicians alike will need to develop strategies to meet these new challenges.

POINT: Is It Time for Pulmonary Concierge Practices? Yes

First let me start by saying that I truly enjoy practicing pulmonary, critical care, and sleep medicine. I entered the field of medicine for all of the same reasons that most other individuals chose the profession: The ability to make a difference in the lives of others, intellectual curiosity, and lifelong learning. I have experienced the practice of medicine in several different clinical settings, including a brief career in academic medicine, 12 years in private practice, and currently as an employed physician.

Treatment of Obstructive Sleep Apnea: Choosing the Best Positive Airway Pressure Device

Positive airway pressure (PAP) remains primary therapy for most patients with obstructive sleep apnea (OSA). CPAP, APAP, and BPAP are all reasonable therapies that can be used for patients with uncomplicated OSA across the spectrum of disease severity. BPAP should be considered for patients who are nonadherent to CPAP or APAP therapy because of pressure intolerance. Several additional factors should be considered when choosing the type of PAP device for a given patient, including associated symptoms and comorbid medical problems, cost, access to online data management and patient portals, and the portability for the device for patients who travel frequently.

Rebuttal From Dr Freedman

journal.publications.chestnet.org 2. We have three major “diagnostic” strategies: (a) straight to therapy with autoadjust positive airway pressure (PAP) 7 ; (b) home studies, albeit with a large variety of diff erent equipment with limited standardization as Dr Freedman 1 indicates; and (c) the traditional standardized in-laboratory polysomnogram. Standards for laboratory studies were developed many years ago. Th e question is: Which patients are best served by use of these diff erent approaches? 3. Once diagnosed, how is therapy best initiated? Do durable medical equipment companies provide value and what is expected of them? 4. Who should manage the millions of patients with OSA in the United States? Should this become the province of primary care physicians if they receive relevant training? Or should we seek to amplify the impact of sleep medicine physicians with a team approach using nurse practitioners, retrained sleep technologists who can act as sleep medicine coordinators, and so forth? 5. What are the outcomes of care that would be documented to show that our care is of high quality? 6. How should we approach chronic care management? Who will be the primary staff doing this? What training will they need? Will insurance pay for this essential service? What information technology resources, including mobile health approaches, do we need to facilitate this? How do we get patients to participate in their own care? What is the role of social media? 7. When do we switch from PAP therapy to alternative approaches when PAP fails? What are the criteria for “PAP failure”? What is the role of the diff erent alternative therapies?

A Sleep Medicine Curriculum for Pulmonary and Pulmonary / Critical Care Fellowship Programs – A Multi-Society Expert Panel Report

BACKGROUND: Pulmonary medicine specialists find themselves responsible for the diagnosis and management of patients with sleep disorders. Despite the increasing prevalence of many of these conditions, many sleep medicine fellowship training slots go unfilled, leading to a growing gap between the volume of patients seeking care for sleep abnormalities and the number of physicians formally trained to manage them. To address this need, we convened a multisociety panel to develop a list of curricular recommendations related to sleep medicine for pulmonary fellowship training programs. METHODS: Surveys of pulmonary and pulmonary/critical care fellowship program directors and recent graduates of these programs were performed to assess the current state of sleep medicine education in pulmonary training, as well as the current scope of practice of pulmonary specialists. These data were used to inform a modified Delphi process focused on developing curricular recommendations relevant to sleep medicine. RESULTS: Surveys confirmed that pulmonary medicine specialists are often responsible for the diagnosis and treatment of a number of sleep conditions, including several that are not traditionally considered related to respiratory medicine. Through five rounds of voting, the panel crafted a list of 52 curricular competencies relevant to sleep medicine for recommended inclusion in pulmonary training programs. CONCLUSIONS: Practicing pulmonary specialists require a broad knowledge of sleep medicine to provide appropriate care to patients they will be expected to manage. Training program directors may use the list of competencies as a framework to ensure adequate mastery of important content by graduating fellows.