How Sleep Medicine has Evolved: From Diagnosis to Patient Outcomes
Sleep medicine is always evolving, and the need for people to gain more knowledge and experience as a registered sleep technologist is growing. As a current or prospective sleep technologist, it’s important for you to know how sleep medicine has evolved to focus more on patient education and positive treatment outcomes.
Sleep medicine evolutions have been impacted by:
- Changes in approach
- Changes in diagnosis methods
- Changes in technology
Detailed information on each of these evolution factors is included below.
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Introduction & History
People have been questioning sleep for millennia, since primitive Greek scientists and philosophers. However, any writings on sleep have been subjective and nothing more than guesswork in scientific understanding.
For instance, in 500 - 450 B.C.,the earliest documented theory on the subject from Ancient Greek physician Alcmaeon was that sleep was simply a loss of consciousness as people's blood retreated from the surface of their body.
Rechtschaffen et al conducted experiments on rats to determine how important sleep was to good health. In these experiments, the rats died of sleep deprivation within two to three weeks.
The rats lost weight and became hypermetabolic with progressive sleep deprivation despite increasing food intake. The rats developed skin erosions of the gastrointestinal tract and skin lesions and right before their death, they developed hypothermia. Further investigation showed that the rats died of sepsis and by that, suggested sleep deprivation might impair the body's immune system from being able to deal with an infection.
Sleep deprivation consequences can be catastrophic. In fact, the Report of the National Commission on Sleep Disorders Research reports that sleep deprivation combined with fatigue causes public disasters, like the Three Mile Island nuclear meltdown and the Exxon Valdez grounding.
Each year, driver fatigue and drowsiness cause 100,000 motor vehicle accidents, according to the US National Highway Traffic Safety Administration. Around 20 percent of the US workforce suffers from different levels of sleep deprivation severity due to shift work.
The workings of sleep continued to be a mystery up until the mid-20th Century advances. Since then, comprehension of sleep has progressed in giant strides, but there’s still necessary work.
Sleep science has seen major advances over the past half-century since the discovery of rapid eye movement (REM) in 1953. Physicians have strived to gain more knowledge needed to diagnose and treat sleep disorders thanks to an increasing recognition of the prevalence of sleep disorders and scientific progress.
Since then, sleep medicine has progressed and evolved. Technologic advances, over the past 50 years, have led to significant lifestyle modifications and combine an abundance of medical knowledge and scientific information to create a need for doctors trained in diagnosing and managing sleep disorders.
Changes in Approach
The sleep industry has evolved in two major ways:
1) Sleep technology has become a specialty.
Through history, the practice of sleep medicine has been a sub-specialty by doctors with backgrounds in:
- Family practice
- Internal medicine
Recognition of sleep being a designated sub-specialty, American Board of Medical Specialties certification examinations, and accreditation of fellowship sleep medicine training programs has led doctors to increasingly choose the field of sleep medicine as their primary practice. In the healthcare realm, practitioners of sleep medicine frequently interface with many other physician specialties.
2) More focus has shifted toward patient outcomes and satisfaction.
Sleep technology education for the year 2018 and beyond should include methods that best improve patient outcomes. CPAP has always been the main obstructive sleep apnea (OSA) treatment after a night in the sleep laboratory receiving a polysomnography (PSG) diagnoses a patient with the condition.
But, technology evolves over time, and there may be new approaches that can offer alternative technologies and therapies that will improve sleep medicine. One such therapy is oral appliance therapy (OAT), and it can be combined successfully with either home sleep apnea testing (HAST) or PSG.
The sleep medicine field is incorporating innovative technology on many levels. Each step implements technology that enhances the way patients receive care, from evaluation and diagnostic testing to remote monitoring and treatment.
Not to mention, sleep professionals are dedicated to delivering personalized and precision care. From the home front to the sleep lab, health care professionals are able to diagnose and treat difficult sleep-related breathing conditions more efficiently because of the addition of sophisticated algorithms on PAP devices and sleep testing platforms.
As a sleep technologist, you're encouraged to advance your skills in the evolving sleep medicine field as the evaluation and treatment of OSA is approaching empiric treatment with auto CPAP and home sleep testing.
You will have to learn more about cardiovascular and pulmonary disorders that affect breathing and sleep, and position yourself to provide care for patients with difficult sleep-related breathing disorders like chronic respiratory insufficiency, central sleep apnea syndromes, or hypoventilation syndromes. It's also important to develop skills and knowledge on in-lab testing, which include advanced titrations that have complex modes and providing proper education to patients regarding advanced modes of therapy.
Changes in Diagnosis Methods
It used to be that your physician would request patients to complete a sleep log in order to learn about their sleep history and diagnose them with a sleep disorder. While obtaining your sleep history is still a component of diagnosing sleep disorders, today, physician use additional tools, like in-lab and at-home sleep studies to arrive at their diagnosis.
The first sleep lab was created in 1925. American Nathaniel Kleitman, who was born in Russia, opened the first sleep laboratory in the world at the University of Chicago so he could continue researching sleep, circadian rhythms, sleep deprivation, and wakefulness regulation.
In-Lab Sleep Studies
Today, you can obtain a thorough evaluation of your patient' sleep in an in-lab sleep study. It's an efficient way to diagnose your patient properly with a sleep disorder. You're required to prepare and monitor the recording of abnormal and normal sleep through technical and collective medical monitors; therefore you're required to have expertise in this part of your job.
You'll need to recognize when medical intervention is required, and use protocols the medical director provides to respond to emergencies in the sleep center.
You may perform an in-lab sleep study for the following reasons:
- Provide testing for particular sleep-related breathing disorders.
- Diagnose narcolepsy or hypersomnia through a sleep study and afterward perform a multiple sleep latency test (MSLT).
- Assess parasomnia-related sleep behaviors.
- Determine why a particular treatment for a sleep disorder isn't working.
- Titrate or calibrate CPAP levels in patients with a sleep-related breathing disorder who are getting CPAP therapy.
- Provide CPAP therapy to patients with a sleep-related breathing condition.
Once you're trained properly and can perform a polysomnography and other types of in-lab sleep studies, you're providing patients and doctors with a very high-quality clinical tool.
Types of In-lab Sleep Studies
A PSG or polysomnogram is a sleep study you perform overnight that records your patient's brain activity, eye movements, oxygen levels, body movement, EKG, and more. You use PSGs to diagnose a variety of disorders including:
- Sleep-related breathing disorders
- Parasomnias vs seizure disorders that occur during sleep
- Sleep-related movement disorders like periodic limb movement disorder (PLMD)
- Sleep-related breathing conditions that lead to excessive daytime sleepiness (EDS)
You may perform a variety of different sleep study tests including:
- CPAP titration
- Overnight sleep study
- Parasomnia vs seizure monitoring
- Maintenance of wakefulness test (MWT)
- Split night CPAP titration study
3. Changes in Technology
New technologies have emerged which change the way sleep disorders are treated.
CPAP (Continuous Positive Airway Pressure)
According to Colin Sullivan, M.B.B.S., Ph.D., FRACP who invented CPAP, the month of June 1980 was a pivotal moment when he first tested his theory that applying positive pressure through the nasal airway could make obstructive apnea stop.
He tested his theory on one patient, leaving the patient on the pressure overnight. The patient slept for seven hours with no signs of apnea and showed sleep patterns that excited Sullivan and his team. The next day, the patient's response equally excited the team. For the first time in years, the patient was fully awake and alert.
Over the course of a few years, the team conducted various experiments where they used the technique to dissect and show sleep apnea's ability to cause adverse outcomes. Sullivan said another pivotal moment for the team was when they tested nasal ventilation for the first time using the CPAP circuit during sleep; they found they were able to manage patients effectively who were suffering from chronic respiratory failure by implementing this system. The frontline treatment now for a number of patients who have respiratory failure is non-invasive ventilation.
Today, physicians now know that patients with sleep apnea often also have cardiovascular diseases; CPAP therapy may help to prevent stroke or heart attack in these patients. Even the comfort of PAP systems has improved today.
Even though it's well-known that nasal CPAP is a good treatment, many people don't realize that it continues to be an extraordinary and experimental method. Newer technologies are continually being tested which often allows for substantial CPAP comfort and design improvements.
BPAP (Bilevel Positive Airway Pressure)
Bilevel Positive Airway Pressure (BPAP or BiPAPTM) and CPAP machines are both non-invasive forms of therapy in their design and function which helps those who suffer from sleep apnea. Back in the 1930s, positive airway pressure was first reported. This was when vacuum cleaners powered facemasks to use for treating pulmonary edema. World War II aviators, a few years later, used the pressure masks at high altitudes to supply oxygen. Since then, the evolution of these early technologies has been incorporated into today's mechanical ventilators.
The design of the BPAP device increases the pressure when your patients are inhaling to keep their airways in their throat and nose from closing while they sleep and provide them with lower pressure while they exhale to continue keeping their airway open. BPAP is more comfortable for many patients than CPAP machines.
APAP (Automatic Positive Airway Pressure)
Automatic Positive Airway Pressure (APAP) is one of the three primary forms of positive airway pressure that provides your patients with sleep apnea with air to their airway to help them breathe while they sleep.
Like other PAP devices, the APAP device connects with a noninvasive mask, connected to a pressure generator. Its design is to keep your patient's airways open while sleeping by delivering air pressure. Various studies indicate that APAP machines are the most popular choice for many patients with sleep stage related or positional sleep disordered breathing.
Technology evolves with time, and newer approaches can offer alternative technologies and therapies to improve sleep medicine most efficiently. While changes in diagnosis and treatment technology play an important role in improving patient outcomes, the recognition that sleep medicine is a specialty is crucial to improvements in sleep quantity and quality and patient satisfaction.
Now that you’ve learned how sleep medicine has evolved from diagnosis to patient outcomes, be sure to download your free 42 page Sleep Technology Terms & Definitions eBook. In this eBook, you’ll receive sleep technology key term explanations associated with routine practice. After reading this eBook, both veteran and new sleep technologists will be able to comprehend and communicate key concepts in common professional language. Get your copy today.