Patient Care
Sleep-Disordered Breathing in the Active-Duty Military Population and Its Civilian Care Cost
A 5-year review of an active-duty service member population found increased costs, prevalence, and incidence of sleep-disordered breathing.
Process
Introduction of this novel alternative therapy has sparked much interest among health care providers (HCPs) at CJZVAMC. However, there has been much misunderstanding among patients and HCPs about what this treatment involves and how it is implemented. For example, many patients that called the sleep clinic to set up an evaluation for UAS did not realize that this is a surgical procedure that requires general anesthesia. One of the most important tasks for a nonsurgical sleep physician is to educate patients and HCPs about this therapy. Most of patient education at CJZVAMC has been done during individual clinic appointments; however, setting up group educational classes for patients is a more efficient strategy to deliver this information. Similarly, giving a lecture on UAS at medicine (or another specialty) grand rounds has been effective in the education of HCPs who refer patients to the sleep clinic. If possible, a combined lecture with a surgical colleague could provide a more balanced and complete depiction of UAS and help to answer a broader range of questions for the audience.
Screening
Screening and identification of appropriate candidates is an important first step in the patient pathway in the UAS therapy. Failure of CPAP therapy is a key starting point in this screening process. When patients present to the sleep clinic with difficulty tolerating CPAP therapy, an extensive and thorough troubleshooting process needs to take place to make sure that all CPAP options have been exhausted. This process would typically include trial of various masks, including different mask interfaces. A dedicated appointment with a registered polysomnographic technologist (RPSGT) or another clinic staff member with vast experience in PAP mask fitting is typically part of this effort.
Adjustment of CPAP pressure settings also may be helpful as high PAP pressure may be another obstacle. Patients frequently have trouble tolerating higher pressure settings especially when they are new to this therapy. Pressure restriction to 4-cm to 7-cm water pressure on auto CPAP has been a helpful technique to allow patients to become more comfortable with this therapy. Once patients are able to use PAP at lower pressures, these settings can be titrated up gradually for optimal effectiveness. Other desensitization techniques, such as use during daytime while distracted by other activities (such as watching TV) can be helpful in adjustment to PAP therapy. Addressing problems with nasal congestion can help improve PAP adherence. Finally, patients should be offered opportunities for education about their PAP machine on an ongoing basis. Lack of proficiency with humidifier use is a very common obstacle and frequently leads to PAP nonadherence. Teaching PAP operation should correspond to the patient’s level of education to be effective. PAP therapy remains the first-line treatment strategy for OSA as it is not invasive and highly effective. Nonsurgical sleep medicine physicians are uniquely positioned to implement and troubleshoot this therapy for sleep apnea patients before considering UAS.
As part of the screening process, it can be helpful to conduct routine multidisciplinary meetings to discuss patients who are being evaluated for UAS implantation. These meetings should include the otolaryngologist, nonsurgical sleep medicine physician, as well as additional staff (nurses, respiratory therapists, etc) who are involved in the UAS process. Having a mental health care provider as part of the multidisciplinary team during the screening process also could be a valuable addition as this specialist could evaluate and provide insight into a patient’s emotional status prior to implantation. This is common practice during evaluation for organ transplantation and would help to predict patient’s psychological well-being after this life-changing procedure.16 Having multidisciplinary agreement on patient’s candidacy for UAS therapy could improve long-term success of this treatment. Additionally, these multidisciplinary meetings as part of the UAS program can improve team camaraderie and prevent miscommunications during this therapy.
