I have talked about mask fit before (here and a little bit here) but I believe that we can never talk about it enough. Mask fitting is one of the most important parts of a titration study. It will be what determines success. It is one of the biggest challenges you face since many patients will make decisions that may not be right for him or her.

Everyone has a favorite mask but I find that it is essential to give the patient at least two choices. Sometimes it can take five or six masks before the patient finds one that he likes. The one thing that will help for the DME company and billing is if you document all the trial masks. This is especially true if you are going to switch to Bilevel therapy.

Last week, we had several different patients who had mask challenges. We had a man with a full beard who would not wear a nasal mask or pillows. We finally got him on a FFM but the leak was ridiculous.  He was placed on Bilevel because that seemed to work better. Ultimately, he was not completely titrated but he was significantly better and he said he felt better. I am hoping that he will trim his beard.

Another patient had failed CPAP previously. The patient was originally placed on pillows because she was claustrophobic. The truth is that most patients who have this problem do not do well on pillows because they cannot breathe through their mouth. It actually makes them more claustrophobic. She was placed on a FFM which she did very well on and thanked us the next morning for helping her. I have also had success with the Fitlife mask for the claustrophobic patients.

My final patient will never use a CPAP or Bilevel. He refused to even try on a mask. In the end he walked out AMA. Unfortunately he had severe CSA and he has very little options for treatment. 

What ultimately is the cause of success for therapy? When I talk to other techs I have heard that it has to do with how open minded and determined the patient is. Those who come in with a closed mind will never accept therapy and even if they feel better will not use it and find multiple excuses why they cannot use it. However, anyone coming in with at least a little bit of an open mind will usually be successful. 

What tips do you have for techs to help them make the CPAP experience more successful?

We are the sum of our experiences and everything I have done in life has led me to where I am now. And, it's a good place. 

Along the way I have met some really wonderful people and some not so wonderful. But all have affected me and taught me something. For that I am grateful. 

I worked with a group when I first graduated from LPN school whose attitude toward new nurses was "I got mine, you get yours the best way you can." It was hard to work in that environment day in and day out but it made me very independent and secure in my knowledge. I had to grow up fast with that group.

Thankfully there were a couple of senior nurses on evening and night shift (Mrs. Beard and Mrs. Xochityl) who took me under their wings and mentored me those first years. 

I've also worked extensively in the ICU and float team. Great experience! I loved it. I never knew where I would be when I came to work or who I'd be working with. I learned the entire hospital and made friends all over the place. The best of the best to me were and still are the nurses on the team, who, sadly have passed on now. I will never forget them: Keri, the valley girl; Judy, who dubbed me her partner in crime (and I still try hard to live up to it); Muriel a very sweet spirited presence; Bobby, always joking and helping; and Amy, truly an angel among us.

Every experience I had as a nurse prepared me not only for the job but for life. I have the confidence to go anywhere and do anything because of what I've learned and done. To borrow a quip, NURSING, it's not just a job, IT'S AN ADVENTURE!

Editor's Note: Want to celebrate your nursing colleagues? Check out our sister publication, ADVANCE for Nurses, for certificates of appreciation, Twibbons for your Twitter account, and more!

Whether the person is guilty or innocent, the accusation will make people worry that something bad can happen at a sleep lab. This makes it essential that as a lab we develop a plan to help patients feel safe and secure. This is especially true when there are male techs and female patients or one tech and one patient at the facility. We need to plan for these scenarios and to work with our marketing people to make sure they can handle any questions that come up.

The biggest scare, however, is how we help to protect our profession. It only takes the misinterpretation of a move like putting on belts to ruin a life. We have to practice defensive medicine to protect ourselves and our futures. We need to make sure we are videotaping everything.  We need to remember that it just takes one person who may not have the best interests to ruin a career or a facility. 

Katie, my pediatric sleep doctor, and I attended the Pediatric Sleep Scoring Course at the Atlanta School of Sleep Medicine last weekend. It was awesome and I really had a great time. I highly recommend taking these classes. They are very informative and definitely make you a better technologist. The experience is invaluable: curriculum, content, the great people you meet. We had people in our group from Kentucky, New Jersey, Oklahoma, Florida, New York, and even a couple of international attendees. Plus, everything is very well coordinated from the time you register until they drop you off and say goodbye. (And the retail therapy I was able to engage in was pretty good too.)

Now it is time to look ahead to the annual GASP (Georgia Association of Sleep Professionals) meeting this weekend in Atlanta. It is another first class act. I've attended every meeting since the group's inception in Lawrenceville, Ga. Every year we have outgrown the facility we met in the previous year. I think that is fabulous. It speaks to the level of commitment we technologists have to our profession and to the great job the staff and board of GASP do.

And finally, I had planned to go to Nashville on May 9^th for the Sleep Educator Course and sadly, for me, the class is full and registration has closed. Oh well, you can't do it all. I know I will need a break. I will catch the next one.

As part of our lab's initial education, we show a video and give handouts. While we are doing the polysomnography set-up, we explain to patients what we are doing and why we are testing for each of these parameters. If the patient understands what we are looking for and why, then they will understand how each of these parameters affects their sleep. It is a short lesson on multiple sleep disorders. You also can share how they are treated so the patient understands that there are many different disorders that are treated multiple ways.

When you are helping to get patients ready for bed, do you explain about sleep routines and how important they are? We give each patient a sleep tips sheet when they leave the next morning. I also create a quarterly newsletter that reminds people about good sleep habits.

Using some examples from your life may also be helpful to your patient. I may be overweight but I can tell you that doing yoga for 10 minutes every night and every morning will change your body and your life. When I started, I could reach just below my knees and had to adjust many of the positions. Now I can touch my toes, have less back pain, and have seen my body lean out.

If you are looking for ideas to add to your sleep routine there are many great places to look. I use About.com for exercise and yoga routines. I sign up for newsletters from people I respect. Do an internet search for a person and you will find out if they have a blog or website. Or better yet: create one of your own. The more information we get out there, the more correct information our patients will get.

We need to be the resource that our patients turn to when they have questions. It is what will create a profession we can be proud of. When we create value for the doctors and patients, we create our own job stability. The more we share our successes with other technicians the stronger our field becomes.

Share with us what you do to educate your patients!

Editor's Note: Looking for handouts to help your patients? Check out our collection of sleep disorders testing and treatment patient handouts at: http://respiratory-care-sleep-medicine.advanceweb.com/Article/Sleep-Patient-Education-Handouts.aspx  

1) RPSGT determines optimal CPAP to be 9-11 cms H2O and the doctor prescribes CPAP 8. Patient returns complaining of snoring and fatigue. Hmmm.

2) Sheldon Cooper-archetype who debunks sleep studies as "hokum" is forced to have a sleep study and surprise, surprise, is found to be severe.

3) Overworked sleep tech has 4 days off, returns to work, and finds way to be more efficient at routine tasks. (I like'm, I love'm, I want some more of ‘em.)

4) Sleep tech finds that increase in activity (walking) is a great stress-buster and actually helps her sleep better...who'd have thunk it?

5) Patient is on CPAP 11 at home and falling asleep at work and while driving but doesn't understand why he needs to have another sleep study.

6) Mid-April in Augusta and 30 degrees last night? Hmmm. Where's Spring?

7) Sleep techs moonlights for every lab in area. We're one big happy family.

8) College student up all night and sleepy all day...hmmm

9) Boss makes special schedule arrangements for tech and then he still can'tmake the schedule work.

10) Finally, manager develops bald spot and rash on back of head accompanied by mumbling and facial tics.

Keep on keepin' on folks.  It's why we do what we do.

The next two people who answered my questions are people who I have learned a great deal from. Henry Johns is one of the original leaders in the sleep field. When I worked in Kansas City, he was the man you wanted to learn from. He is one of the original sleep techs who helped shape our field. Anglee Leviner has no problem expressing herself. She recently was recognized with an AAST award for her writing. She shares her knowledge with those who are new to the field. She will be part of the future of sleep medicine.

How did you get into the field?

Henry Johns (HJ): I was a respiratory therapist working in an ICU in 1988, when a pulmonologist handed me an article in CHEST about apnea and cyclic desaturation. He asked me if we could start doing sleep studies and I said "Yes." I had no clue what I was talking about, but soon found myself sitting with a Grass Model 6 & Omedia oximeter. Within a year, we had a Vitalog system and were doing home testing.

Anglee Leviner (AL): There's nothing grand or glamorous about how I started in sleep. Like many people in my generation, I lacked direction after high school and some college. Being unsure what the life plan was, I went on an adventure on the west coast to find myself. There was no plan to ever come back, but months in, I was bored with doing nothing. My mother called me one day and said "Anglee, there's an opportunity to start a profession I know you'll enjoy, get your behind home!" As much as I dislike admitting it -- she was right. My mother trained me, on the job, and the rest is history!

Why did you decide to go into the leadership role? 

HJ: I have never thought of myself as a leader as much as a guy who can't say no. I was never a leader in HS or College. I volunteered for the AAST (APT) in order to give something back to the field. I served on the program committee and was appointed vice chair and then chair. At the same time, I became a site visitor for the CoA PST, was appointed to the board of directors, and am now president elect.

AL: Through online networking, I became aware of the issue born of the new exam the American Board of Sleep Medicine (ABSM) had announced. Based on the information I was receiving, I became involved in finding solutions and ways to arm my fellow sleep technologists against what I was told was a threat. As anyone who knows me in any capacity will quickly confirm, I'm fond of playing devil's advocate in order to strengthen my own and other's viewpoints. Doing this allows one to prepare for debate with the other side when it arises, and to not be caught without a response to their points. During my research and discussion of the new exam, I uncovered numerous inconsistencies and exaggerations. I felt as though I was suddenly standing in the eye of a hurricane, calmly able to see all the lies and strife. The online community of networking sleep professionals isn't large or connected enough to spread the information, so I decided I needed to write an informative article. After that, it became clear to me just how much writing impacted the field. Writing is something that has always come very easy for me. And where I come from, using our time and talents to help the community is just what people do.

What is the most important lesson you have learned while working in the field of sleep? 

HJ: That everyone brings something to the table in this profession and that is what makes it such a dynamic field. As I said, I was (still am) an RT, that body of knowledge is what I bring. I have worked with R. EEG. T.'s who taught me volumes in exchange for what I offered.

AL: Pick your battles. I've passed this advice on many times to professionals frustrated with their management or medical direction. When a mistake in treatment, reporting, ordering, the whole process is just a matter of pride, I've found it's best to let it go. If a mistake in those matters endangers the patient, compliance, or appropriate treatment -- stand up for the patient's best interest.

What is the funniest thing that has ever happened to you while working? 

HJ: There have been a lot of moments over the past 24 years. One of the best was a quiet night with two seemingly normal patients. I was nodding off and getting that 3 a.m. whiplash when the female patient began to scream at the top of her lungs and wave her arms. It startled me so that the chair rolled out from under me, I almost hit the floor, jumped up, grabbed a flash light, ran to her room only to find her quietly sleeping. I sat for a long time trying to figure out what happened, rewound the video tape to see if it really happened or not. It was my first case of night terrors.

AL: I was working in a new lab, and new equipment can take some acclimation time. I could not for the life of me figure out why the PTAF signal was not coming through. All wires were plugged in the appropriate spots, switches flipped on. So I called support and explained how everything was where it needed to be. "Did you check the batteries?" he asked. I didn't realize it took 9V batteries! How embarrassing.

What do you see for the future of sleep and of sleep technicians?

HJ: I think the future of sleep is going to be as exciting and dynamic as the first 40 or so years have been. There is still so much to learn and discover about human sleep. New fads come and go, new technology, new practice models, but the challenge is still there. Every night.

AL: In the future of sleep, I see innovation, variety, and genius. The sleep technicians who do their job, and leave it behind at work will give in to the idea that home sleep testing is replacing us. They will give in, and move on to a new field. The genius within the field will conceive of a new role. This concept is very exciting; I'm sure I'm not the only one who sees redundancy in the NPSG-PAP model of work. Once in a while we have the opportunity to get excited about a rare or complicated case, but not often. The Thornton Adjustable Positioner (TAP) does not have an auto adjusting capacity yet. The bridge between the dental sleep medicine world and our polysomnography world is coming together. Sleep technicians will be needed across that bridge. The variety of tasks that we, as sleep technicians, will be able to apply our knowledge and education to is staggering. And I, for one, cannot wait to jump in and experience it all!

It seems I am always behind in reading my magazines, newsletters, Facebook, and email. After being on the computer all day at work, sometimes the thought of all that extracurricular reading is just more than I can bear. (Remember in the olden days when once you clocked out and left work it actually meant that work was over? You were done for the day... I miss my free time.) So, it should come as no surprise to you that I just finished reading the Wake-up Call newsletter published by the ASAA.

I was very interested to read about the pediatric A.W.A.K.E group started in Connecticut by Norwalk Hospital. Kudos to them!! We too see a lot of pediatric patients, a good many of whom require CPAP. I always inform them of our A.W.A.K.E group meetings but in the two years we've been meeting I've had only one mom come. I was very encouraged at the success that Norwalk is having. It has inspired me to reconsider a separate meeting for our kids. The stories the participants shared we so gratifying to hear.

Our pediatric sleep population runs the spectrum from your average kids with big tonsils to the severe impaired breathers with genetic syndromes and multiple complicated medical issues. We are the only children's hospital in our area and we do have several support groups and camps for kids. Maybe it's time for us to consider adding A.W.A.K.E as well.

Thanks ASAA Executive Director Ed Grandi, for the newsletter.

Last week, there were horrendous tornados in the Midwest.  One of our own saved her children at great personal sacrifice. Stephanie Decker has lost both her legs. She also lost her house and all her family's belongings. What she needs from us now is support, both financially and in your prayers. A fund has been created to support Stephanie at http://holidaycharities.chipin.com/hero-mom-stephanie-decker. She gets 100% of what is donated. 

I can think of no better way to send her a message that we as community support her in her long journey.  

Editor's note: As a 175 mph tornado roared above her house, Stephanie Decker threw a blanket on top of her children and then laid on top of them in an attempt to shield them from the storm. Read the full story, as she told to the Daily Mail from her hospital bed, here: http://www.dailymail.co.uk/news/article-2110995/Stephanie-Decker-lost-legs-saving-children-Henryville-Indiana-tornado-2012.html

Last I wrote, I had just experienced one of the most rewarding interactions a sleep tech can have with a patient. You'd think the universe would just let me revel for a moment, but no. Instead I got swept out to sea and thrashed about by a brutal storm. You know what that's like. From out of nowhere a rogue wave crashes into you, swamping your boat, sort of like those billing codes and ever-changing reimbursement guidelines I'm struggling to work within this week. 

And then while you're disoriented and treading water you notice the dreaded shadows begin to appear. Frantically trying to keep an eye on their every movement in an attempt to maintain your composure and stay ahead of them. Not so dissimilar to the myriad of scheduling challenges I faced last week, sick patients, urgent add-ons, insurance cancellations, hungry sharks all taking their bite. 

Or maybe from out of depths a rampaging kraken rises up screaming and swatting, terrorizing all on board. Once in the grasp of the kraken, a boat is doomed.  Krakens can come in many forms, I'm sure we all know at least one. My kraken appeared in the form of data error messages on every work station and a server that went down, forcing me to cancel patients at the last minute. Kraken takes the win.  Tired and bewildered sleep tech drowns. 

The ebb and tide of the weekend rolls in. Bodies will be rested, heads cleared and souls renewed. Alas, Monday will dawn. I think this weekend I will just change my name: Call me Ishmael...

Below are the answers from Melinda Trimble RPSGT, RST, (the first person I asked) and James Krainson MD, FCCP FAASM, RPSGT, someone who is truly dedicated to helping technicians to get educated and has donated his time to Florida Association of Sleep Technologists (FAST).

How did you get into the field?

Melinda Trimble (MT): It was 1987. I was working as a respiratory therapist at a local hospital when one of the area neurologists, Dr. David Brown, opened up the first sleep center in northwest Arkansas at Washington Regional Medical Center. The head of the respiratory department at Regional asked me if I wanted to learn to be a sleep technologist. I was very interested, but it was such a new field of medicine that I almost did not take the offer.  Looking back I am so glad I said yes!

Dr. James Krainson (JK): I had a strong interest in sleep starting with my training at Mount Sinai. I saw how many people were not being helped because other physicians had no training in sleep. I decided to help my patients and be an advocate for sleep disorder awareness at the same time.

Why did you decide to go into the leadership role? 

MT: In 1999, I developed an educational training program for sleep technologist at Washington Regional. Part of that program was a yearly regional meeting. It was during a meeting in Branson, MO that I met Kelly Million, then-president of the APT (Association of Polysomnographic Technologists). Kelly approached me and told me how wonderful the meeting was and asked if I would be interested in working with the APT as the education committee chair.  As they say, the rest is history.

JK: I have always wanted to be a teacher. At this time of my career, I can still practice and find time to teach.

What is the most important lesson you have learned while working in the field of sleep? 

MT: The value of friendship.  I have had the most wonderful experiences over the last 24 years. The friends who I have made, I will value and hold dear for the rest of my life. It has been a wonderful journey.  

JK: The same message that I learned early in medical school. Always listen to the patient and respect the fact that, both medically and otherwise, every patient is unique.

What is the funniest thing that has ever happened to you while working? 

MT: I am not sure; I have had so many fun and enjoyable times as a sleep technologist.   I am sure my staff would love to answer this one.

JK: After I treated a patient for his OSA and his libido returned, his wife asked me to tell him to stay away from her. (On the initial visit she complained that he didn't give her enough attention.)

What do you see for the future of sleep and of sleep technicians?

MT: You know that is the million dollar question. I wish I had the answer. I do think we will see changes in health care that will have an effect on sleep and the sleep technologist. As AAST president, I have spent most of my time over the last year trying to bring together the leadership within our field to look at and talk about this very topic. My hope is that as we come together we will start to have a clearer view of the possibilities that are open to us as sleep professionals.

JK: I hope that sleep techs become a more cohesive group, so that the professional goals of the tech can be realized. I am sure that eventually licensure will come about state by state and the profession will become more recognized and respected.

I will share the other three interviews in the coming weeks and will send out these five questions to more leaders in the field. If there is someone who inspires you and you'd like to hear their thoughts, let me know and I'll ask them.

The response to my efforts last year left me a bit disappointed to say the least. I had the lab all ready to receive visitors, sent out piles of invitations, laid out refreshments, and had an arsenal of information at the ready. All I had to do was wait for my "guests" to arrive...which they did...all three of them.  I think my boss felt so bad for me that he was ready to pay people to drop in. Whoever said "enthusiasm is contagious" obviously never tried to help people with sleep disorders. At the end of the day I felt like a little puppy that excitedly dropped his ball at someone's feet only to be shoved aside. 

So it was with some degree of apathy that I approached planning this year's "sleep week."

Then someone visited yesterday that reminded me of why I am here and why we all do what we do. She came to the clinic for a follow up appointment and her doctor suggested she stop by the lab and say hello. I heard her call my name but could not see her. When I did, the woman I saw was not the woman I knew. Who was she? She was the first successful ASV titration I did in a long line of two. That was one year, one hundred and fifty pounds, one wheelchair, one husband, and fifteen surgeries ago for her. "CC" couldn't walk more than a few steps back then, could not complete a thought, and definitely couldn't breathe.

It was only when our eyes met that I recognized her now. She ran in and gave me a big hug and a kiss and said, "You saved my life." She's still on ASV, uses it faithfully every day of the week, and won't leave home without it. "Leave home?" I thought. She not only leaves home but is out of the wheelchair and drives. At age 59, she's not only survived but overcome her illnesses and is starting her life anew....and she thanks me for that. I feel so privileged and humbled to have been a part of her story. 

So I leave you with this as we approach sleep week: remember, it only takes one to make a difference and you only need to reach the one. Keep doing what we do, give it your best every day, and one by one, we will and do make a difference.

Well, I recently had a patient who told me that he has insomnia and cannot go to sleep before 4 a.m. no matter how early he goes to bed. Said patient needs a CPAP titration and, anticipating the problems associated with his complaints, I asked his doctor about a sleep aid for the night of the study. Here's what frustrated me: the doctor said no.

He proceeded to tell me that sleep aids are contraindicated in obstructive sleep apnea and that he could not order a med for this patient. What? Did he just say that? What's wrong with him? I will tell you what's wrong: He is an ENT doc, not a sleep doc. 

I read a study in ENTtoday with three control groups that found that...wait for it...there is not significant evidence to support that use of a sleep aid to help users acclimate to CPAP nor does a sleep aid increase the long-term use of CPAP.  I wonder how many of that group fit the description of this patient, moderate to severe OSA with insomnia and possible delayed sleep phase?  The article did give a nod to the use of sleep aids in specific circumstances that were not really specified.

While I respect a doctor's right to treat his patients his way,  I am really aggravated to think this patient will most likely come for the titration study, not sleep, leave with an unacceptable titration, and probably have to repeat it.  I personally have seen the benefit of using a sleep med to help CPAP users adjust.  I am so accustomed to sleep medicine's way of doing things (which I believe is the right way) that I just can't believe someone would choose the probability of failure. 

I should have asked the sleep doc.

Anyone have any advice to offer?

Follow up in many cases does not happen because no one will pay for it. Decreased reimbursement and capitated contracts have caused many providers to drop off a CPAP machine and never follow up with the patient. But what those companies and the Medicare competitive bidding program have not taken into account is that trained personnel are essential to raising the success rate. These professionals listen to the patient, examine their issues, and come up with the creative solutions to help them become compliant with therapy.  The trained sleep personnel understand how to properly craft a desensitization plan for a patient. They understand the value of proper mask fitting and why different masks work on different faces.

Sleep centers should have the autonomy to change interfaces without a medical prescription. If a patient trials several masks on the night of a titration study, they do not know whether that mask will work long term. The sleep tech does not know if the patient may have issues with skin breakdown or leaking because their pillow is different than the one at the sleep lab. And if a patient loses weight while on therapy and his mask no longer fits, there's no guarantee that he will see his primary care physician and receive a script to refit the mask. A mask change should just be able to happen with a proper fitting at a lab or DME company. 

And although many patients are being followed by a sleep specialist, more are being followed by their primary care doctor. Reimbursement amounts do not cover referrals for follow-up by the sleep labs (although many centers do call patients, have newsletters, and host support groups) or for DME companies that set up the patients. 

In order to change the issues, we need to make it clear that CPAP failure is truly about failure to interact, and interactions must be reimbursed. We cannot save money on trained personnel in the short term without taking into account the long-term effect on therapy success rates. We, as a community, need to make it clear to patients, the medical communities, and the insurance companies that with proper reimbursement enabling proper care of patients, this therapy can be successful.

Altman has been a member of the BRPT Board since 2010 serving as chair of the website development committee, an active participant on the exam development committee, and, this past year, as president-elect. She is the technical director for the Creighton University Sleep Disorders Center in Omaha, Neb.  Her two-year term as president begins this month.

I also would like to thank Janice East for the time she put in serving as the president of the BPRT.  Janice, I believe served prior to Mark DiPhillipo and again after his term as president. (Mark DiPhillipo was president when I became registered.  I have never met him but I did have the pleasure of meeting Janice last year at the ASET meeting in Atlanta.  I may have met Cindy too, her face is so familiar, but I just can not remember.  That was an action packed, fast paced meeting.  At any rate...)  I think we are all very fortunate to have had Janice as long as we did.  Her commitment to her profession is truly honorable.

And now the torch is passed to Cindy Altman and to her I say "welcome." This position is a tremendous amount of work and a challenge that I hope she finds rewarding. I look forward to meeting her and feel sure she is ready to drive us on.  The vehicle that is sleep looks like it may be a wild ride.

Thanks ladies for all your efforts on behalf of sleep technologists everywhere.