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We spend a third of our lives asleep –that can be a long time of fitful rest for someone who experiences sleep problems. Disruptions in this state of rest can lead to a decline in one’s overall quality of life. Most patients with sleep problems first seek medical help from their primary care physician.

Sleep in the Primary Care Setting:

Poor quality of sleep tends to accompany common illnesses, and life stressors (including family and social structure changes); thus, patients tend to visit their primary care physician who has a complete knowledge of the factors that are related with their sleep problems. Obstructive Sleep Apnea occurs at a high frequency in the primary care practice setting. An estimated 18 million Americans suffer from OSA; yet, despite the volume of sleep complaints to the primary care physicians, they often go unaddressed.

Common OSA facts and its associated health risks

• OSA is more common in men, and those over the age of 40.
• Snoring (Sleep Disordered Breathing) can be a sign of sleep apnea.
• Adult OSA has a long-standing and unambiguous correlation with obesity and daytime sleepiness. The National Sleep Foundation Sleep in America poll found that 77% of obese adults report having sleep problems. ¹ Sleep specialists say that weight gain, especially in the trunk and neck area, increases the risk of sleep-disordered breathing due to compromised respiratory function.¹ Research shows that sleep problems, like sleep apnea, also result in weight gain which can lead to additional health problems.¹
• Epidemiologic studies have linked sleep apnea with potential, long-term cardiovascular risk.
• Other studies have noted the consistent and strong association between OSA and hypertension.

Diagnosis and Management of OSA

Patients normally go to a sleep lab for OSA diagnosis & evaluation. Often, this causes the primary care physician to loose direct view of his/her patient’s sleep condition. An alternative to sending patients to a sleep lab test is to begin the diagnosis and management process within the primary care setting, by utilizing newer technology that makes sleep diagnosis portable and more readily accessible. Today, diagnosis and therapy of OSA should be considered as part of the health plan to manage diabetes, hypertension, and congestive heart failure — which are all core aspects of primary care medicine.

In conclusion, with training in sleep and an understanding of appropriate testing procedures, primary care physicians can use current evidence based information in the field to provide high-quality sleep medicine in the primary care setting.

As promised in my earlier post “Tips for a Good Night’s Sleep” here is a guide to making your own sleep log. We discussed that if you can’t seem to get quality sleep despite efforts and suspect that you might suffer from a sleep disorder, it’s a great idea to create a sleep journal. This is a great source of information for you and for any medical professional you talk to about you sleeping problems. Some physicians suggest recording your sleep information for a week while others recommend recording for two weeks.

Make a chart (as shown below) where you record the following for a week or two:

• Day/Date
• Time in Bed: The final time of day you got into bed to go to sleep.
• Time out of Bed: The time of day that you got out of bed for the last time in the morning.
• Time Asleep: The estimated time of day you feel asleep for the first time.
• Awake Time: The estimated time of day you awoke for the last time in the morning.
• Anything Unusual (bathroom at night or trouble sleeping etc.)
• How many caffeinated beverages did you have that day?
• When was your last meal before bed?

Also note your height, weight and any medications you are on. I have attached a sample sleep journal below.

Also, thanks to everyone who participated in the comments and discussion regarding Tips for a Good Night’s Sleep!

Sample of Sleep Log or Sleep Journal

If you don’t want to miss a minute of life to groggy-tiredness, you need a full night’s sleep. Moreover, there are personal habits you can cultivate to help you sleep more effectively. I hope that these tips help you get some much needed, quality rest!

Sleeping Environment

• Use comfortable bedding.
• Keep a livable and constant temperature (75°F to 54°F) while you sleep.
• Keep pets outside the bedroom.
• Keep the bedroom quiet and block out noise.
• Reserve your bed for sleeping. Avoid staying in bed if you’re not sleeping within 15-20 minutes.
• If you can’t fall asleep get up and go to another room and do something relaxing such as reading.

Before Bed Time

• Take only a light snack such as warm milk. Heavy meals can cause your body to work to digest food and interrupt your sleep.
• Practice relaxation techniques before bedtime so you don’t take your worries to bed.
• Develop a pre-sleep ritual.
• Set a consistent time everyday to go to bed and to wake up. It takes your body time to adjust to changes in your sleep pattern; a good example of this is jet lag.

Personal Habits

• Avoid eating 2 hours before bedtime.
• Exercise during the day up to 2 hours before bed.
• Avoid naps during the day.
• Avoid caffeine 6 hours before bed.
• Alcohol is a depressant and may help you fall asleep but keeps your body awake processing it. Avoid alcohol 6 hours before bed.
• Nicotine is a stimulant and should be avoided particularly near bedtime and upon waking up at night.
• Bright lights and TV keep you awake and have a negative affect on sleep.
• Clear you mind before bed time, stop working on tasks 2 hours before bed.
• If you can’t seem to get quality sleep despite efforts and suspect that you might suffer from a sleep disorder, it’s a great idea to create a sleep journal. Try and keep track of your time in bed, time asleep, time awake, time out of bed and personal habits for each day. This is a great source of information for you and for any medical professional you talk to about you sleeping problems (I will work on posting an example of this in the future).

There are dozens of other tips to a good night’s sleep and some of these are not the same for everyone. If you have more advice to add to this list, feel free to comment on this post and we’ll continue the discussion!

In this week’s post we decided to write about one of the more popular topics suggested by our readers: definitions of types of sleep studies devices according to CMS (the Center for Medicare & Medicaid Services) and AASM (the American Academy of Sleep Medicine). Hope these quick summaries help in understanding these terms better. CleveMed currently has three devices that fall within these defined categories for the purposes of sleep (Type I - Sapphire PSG, Type II - Crystal Monitor PSG, and Type III - SleepScout).

Definitions according to Center for Medicare & Medicaid Services (CMS) Guidelines

Type I – Attended studies (Sleep studies that are preformed with the oversight of a sleep technologist.) with full sleep staging (Sleep staging monitors the transition through the sleep stages. Traditionally with the use of EEG electrodes that monitor the brain). Type I devices must includes the following channels:

• EEG
• EOG
• ECG/Heart rate
• Chin EMG
• Limb EMG
• Respiratory effort at thorax and abdomen
• Air Flow from nasal canula thermistor and/or X-Flow (AASM re- commends RIP technology
• Pulse Oximetry
• Additional channels for CPAP/BiPap levels, CO2, pH, pressure, etc.

(CPT #95810 Baseline PSG, 95805 MSLT, 95811 Titration)

Type II – Home sleep study test (HST) with type II portable monitor, unattended(Sleep studies that are preformed without the oversight of a Sleep Technologist.); minimum of 7 channels. Type II devices must includes the following channels:

• EEG
• EOG
• ECG/heart rate
• EMG
• Airflow
• Respiratory effort
• Oxygen saturation

(HCPCS #G0398)

Type III – Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels. Type III devices must includes the following channels:

• 2 respiratory movement/airflow
• 1 ECG/heart rate
• 1 oxygen saturation

(HCPCS #G0399, CPT 95806)

Type IV – Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels. Type IV devices must allow channels that allow direct calculation of an AHI or RDI as the result of measuring airflow or thoracoabdominal movement. Alternatively devices that record other information to derive AHI or RDI must be approved by CMS through the review of published peer-reviewed medical literature.
(HCPCS #G0400)

Definitions according to American Academy of Sleep Medicine (AASM) Guidelines

Type I - Monitoring devices perform in-laboratory, technician-attended, overnight polysomnography (PSG) and are discussed separately. (CPT #95810 Baseline PSG Study, CPT #95805 MSLT Study and CPT #95811 Titration Study (CPAP))

Type II – Monitoring devices can perform full PSG outside of the laboratory. The major difference from type 1 devices is that a technologist is not present. These devices are called comprehensive portable devices. (CPT #95807)

Type III – Monitoring devices do not record the signals needed to determine sleep stages or sleep disruption. Typically channels include:

• Four physiologic variables are measured including:
• Two respiratory variables (eg, respiratory movement and airflow)
• Cardiac variable (eg, heart rate or an electrocardiogram)
• Arterial oxygen saturation
• Some devices may have other signals including a monitor to record snoring, detect light, or a means to determine the body position.

(CPT #95806)

Type IV – These devices are called continuous single or dual bioparameter devices. Monitoring devices record one or two variables and can be used without a technician. Typically channels include:

• Arterial oxygen saturation
• Airflow