“It ain’t rocket science,” said Richard Bonato, PhD, Co-Founder and CEO of Braebon, a global single-source provider of PSG sensors, accessories, snoring and home sleep apnea recorders, and therapeutic intraoral appliance compliance measurement, headquartered in Ottawa, Ontario, Canada.
Bonato was glibly referring to the process of diagnosing sleep apnea which, he believes, does not require a trip to a sleep laboratory for many patients. Indeed, Bonato said most sleep apnea can easily be detected through some clinical observations and a home sleep apnea test. And while some sleep laboratories and sleep medicine professionals may fear that such proclamations could mean disaster for the business side of sleep laboratories, Bonato said nothing could be further from the truth.
“I was out shopping for a car, and got talking to the salesman who mentioned he had was tired – hadn’t slept well. I noticed he was heavy-set, had a large neck. I asked him to stick out his tongue – it was scalloped around the edges. I asked him if he had any nicks or signs of wear and tear on his teeth along the gum line. He said, ‘You mean these?’ pointing to abfractions. So I said, ‘Do you snore?” and he said, ‘My wife says I do.’
“Boom. I knew he had sleep apnea,” said Bonato, adding that tongue scalloping provides 71% positive predictability for sleep apnea; snoring plus tongue scalloping ratchets up the positive predictability for sleep apnea to 80%.
“I said, ‘I think sleep apnea is your problem,'” Bonato continued. He got tested, and was positive for severe sleep apnea. He got CPAP – couldn’t tolerate it. So he lost weight, and that solved it. He said he feels like a new person. Oh, and I didn’t buy the car from him because he wouldn’t meet my price.”
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Questions Start the Process
The story was told to prove the point that sleep apnea, unlike rocket science dilemmas, can often be detected through a screening questionnaire. Bonato suggested the “STOP-BANG” questionnaire that asks for the following patient information:
Height _____ inches/cm
Weight _____ lb/kg
Male/Female BMI _____
Collar size of shirt: S, M, L, XL, or _____ inches/cm
Neck circumference _____ cm
1. Snoring — Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? Yes or No
2. Tired — Do you often feel tired, fatigued, or sleepy during daytime? Yes or No
3. Observed — Has anyone observed you stop breathing during your sleep? Yes or No
4. Pressure — Do you have or are you being treated for high blood pressure? Yes or No
5. BMI — BMI more than 35 kg/m2 ? Yes or No
6. Age — Age over 50 years old? Yes or No
7. Neck circumference — Neck circumference greater than 40 cm? Yes or No
8. Gender — Male? Yes or No
High risk of OSA: answering yes to three or more items
Low risk of OSA: answering yes to less than three items
“If a patient answers yes to five or more of those questions, they are at a high risk for apnea; three to five yesses indicates an intermediate risk. If the STOP-BANG questionnaire leads to high probability, then you can do a home sleep apnea test,” said Bonato. “Some people in the industry say with home sleep apnea testing this or that can go wrong, but that’s when I say, ‘No, it’s really quite simple. It’s not rocket science.'”
New Age of Sleep Apnea Testing
He also said that, “Sleep lab testing developed as the industry paradigm because it was once required for insurance reimbursement for certain therapies, such as CPAP. But in 2008 CMS ruled that you can diagnose any way you want – that was a game changer. A new age is dawning.”
Bonato said that sleep laboratories are not the norm in other parts of the world, due in part to the expense. Another reason is the fact that there just are not enough sleep laboratories to diagnose the hefty population of people with sleep apnea. “Think about it. Even here in North America, how are you going to screen and diagnose 20% of the population? That’s 70 million people. There will never be enough sleep laboratories to handle that epidemic number; there are only about 13,000 sleep laboratory beds in all of North America.”
Home sleep apnea testing is emerging as a crucial tool to reach a large proportion of the affected population. However, that does not imply that home sleep apnea testing will draw patients from sleep laboratories or in any way put them out of business. Bonato said the reality is quite to the contrary.
“Sleep centers are not redundant – they are a different tool and are needed for people who are really hard to diagnose and/or are really sick,” Bonato clarified. “If you have a patient with congestive heart failure, for example, or Parkinson’s, Alzheimer’s, some pediatric or geriatric conditions, or if a home test comes back negative and you want a more definitive test, you will need the patient to be seen at a sleep lab. There are about 90 different sleep disorders, and home sleep apnea testing is only about sleep disordered breathing — apnea, snoring, those types of things.”
The bottom line, said Bonato, is in the numbers. “Home sleep apnea testing identifies more patients in need of help by casting a wider net. The more people you test, the more you will find those patients who really need to go to a sleep lab.” By way of this logic, Bonato believes home sleep apnea testing will actually increase the occupancy rate of the sleep laboratories. In turn, more sleep technologists will be required to distribute devices, take time to educate patients on use, let patients know that if they take care of their breathing at night they are going to feel healthier and more energetic, and pursue follow-up, treatment and compliance. As Bonato sees it, a burgeoning home sleep apnea testing trend is a win for everyone – patients as well as sleep medicine professionals.
Valerie Neff Newitt is on staff at ADVANCE. Contact: [email protected]