Providers

Split studies are a combination of a routine diagnostic polysomnogram and a therapeutic polysomnogram with positive airway pressure titration. Traditionally these are two separate studies performed on two different nights. In some cases, it is reasonable to combine the two studies on a single night for the sake of convenience, expedience and cost containment. However, for most patients this is neither practical nor desirable.

There are regulating influences that restrict the use of split studies. First and foremost, Medicare and Medicaid will not allow split studies unless the first portion of the night shows “severe and unambiguous” obstructive sleep apnea. Further, the study has to include a full three hours of CPAP, which often there is no time for after completing the diagnostic portion. Finally, the study must document that CPAP eliminates or nearly eliminates the respiratory events during both REM and non-REM sleep. Again, time often doesn’t allow this goal. If any of these criteria are not met, the study will be unacceptable by Medicare and Medicaid.

The American Academy of Sleep Medicine also has standards. The Academy is the authority for certification of sleep laboratories. It recommends that split studies be performed only if there is severe obstructive sleep apnea in the first two hours of sleep, specifically there should be 40 or more apneas and hypopneas per hour for at least two hours of sleep. Violation of the standards of the Academy can result in loss of certification of a sleep laboratory.

Another concern regarding split studies is that they limit the sleep time available to test whether positional therapy is effective for sleep apnea. Positional therapy generally involves the avoidance of the supine position and may include certain devices that provide a gravity-neutralizing effect on the posterior displacement of the tongue, palate and mandible during sleep. About a third of sleep apnea patients can be adequately treated with positional therapy, but this requires at least an additional two hours of sleep time to implement.

Our goal is to provide split studies for patients when the first two hours of their sleep study does indicate severe sleep apnea and when positional therapy does not seem like a reasonable option. This turns out to be a minority of patients who undergo polysomnography for sleep apnea.

Pap Nap

We are now able to offer PAP Nap, a daytime procedure lasting from 2-5 hours which includes a nap of 1 to 2 hours and combines hands on coaching (delivered by sleep technicians under the supervision of a physician) providing the physiological experience of positive airway pressure therapy in order to enhance PAP therapy adherence in patients who show skepticism or aversion to PAP use.

Objective of the PAP Nap

To assess, address and alleviate physical, mental and emotional barriers in those patients who would benefit from PAP therapy, thereby liberating them with sufficient confidence to obtain a full night CPAP titration. The primary goal is to help the patient use PAP therapy for more than one hour, during which time he or she has the potential to fall asleep with PAP mask in place or to at least report that the experience was not uncomfortable.

Which Patients Will Benefit

* In particular those with co-morbid conditions such as insomnia (ISI >11), nightmares, anxiety, depression, post traumatic stress disorder, panic attacks, and claustrophobia, including those with past or current history of mental health disorders and/or psychotropic medication usage.

*Those with a strong skepticism about PAP therapy or the possibility of a breathing condition influencing their sleep.

*Patients who have expressed or have the inability to articulate the precise nature of complaints about the breathing mask, i.e. discomfort, shame, embarrassment, fear or anxiety

Evaluation

After polysomnography is performed the patient is consulted about sleep disordered breathing, treatment of OSA and discussion of risks and benefits offered from the option of PAP titration. Those diagnosed with OSA who show fear, anxiety, aversion, a sufficient skepticism to PAP therapy, or have any of the above mentioned co morbidities can be offered the PAP-Nap.

The Procedure

An afternoon nap at the sleep center in a comfortable, private and therapeutic environment is planned.
There are 5 steps to the procedure including, Pre-test instructions, introduction of PAP therapy devices and barrier assessment, PAP therapy hook up, PAP therapy testing and Post-test follow up.