MemorialCare Sleep Disorders Center evaluates patients with nighttime sleep disorders and some who complain of daytime sleepiness or narcolepsy.

D06a.jpg (13678 bytes)A sleep diagnosis demonstration by Vinh-Boi Nguyen

While the awareness and subsequent diagnosis of sleep disorders have increased among those in the medical community and their patients, Steven Lenik, RCP, RPSGT, RPFT, RCPT, clinical supervisor at MemorialCare Sleep Disorders Center, Long Beach, Calif, says both groups still need more education about the problem and sleep studies.

“I’ve seen so much change,” says Lenik, who has been in the sleep medicine field for more than 30 years and wrote Handbook for Sleep Medicine Technologists.

“When I started in sleep medicine, no one knew anything. The public’s awareness and the physicians’ awareness have increased. There’s a lot of ignorance out there still, but not as much as years ago,” he says, adding that many patients still come to the sleep disorders center unaware of why their doctor referred them.

“Most of the patients seen here are referred by a doctor who knows nothing about sleep medicine,” he says. “One of the problems with sleep disorders is that the patient doesn’t usually believe they have a problem. They don’t associate their symptoms during the daytime with what happens in their sleep. They don’t realize it is a health issue. It’s an uphill battle trying to educate the patient.

“I’d say 50% of our patients don’t even believe they have a problem, and the other 50% don’t understand their problem,” he says.

MemorialCare Sleep Disorders Center is run by the respiratory care department of Long Beach Memorial Medical Center, although it is actually located down the street from the hospital. The outpatient facility opened in 1986 and is accredited by the American Academy of Sleep Medicine.

The center is more than 2,000 square feet, and has four patient rooms. Each carpeted room has a bed, nightstand, desk and chair, mirror, small closet, and artwork on the walls. Some of the rooms also have a television.

“We try to simulate a motel room as much as possible to comfort the patients,” Lenik says.

Two of the rooms have adjustable hospital beds, and are larger to accommodate a caregiver when needed.

Each room has a CPAP or bilevel positive airway pressure device on the nightstand next to the bed and is equipped with a video and an infrared camera for monitoring purposes.

The center operates 7 days a week and conducts about 20 sleep studies per week. While the majority of patients come to the center for nighttime sleep studies, there are a handful who participate in a multiple sleep latency test, which is conducted on narcoleptics and patients who sleep well during the night, yet complain of a constant feeling of sleepiness during the day.

Upon a patient’s arrival at the center for their sleep study, a technician explains the process and connects the patient to a monitoring system, which includes 20 electrodes on the scalp and face, as well as ECG electrodes; electrodes on the legs to monitor for muscle twitches; a thermistor pressure cannula to measure expiratory pressure; and respiratory belts to help determine whether there is any obstructive breathing. Patients are also fitted for a CPAP or bilevel device.
The entire connection process can take 30 minutes to 1 hour to complete.

“The most common statement we hear from patients after we finish is ‘How am I going to sleep with all this on me?’” says lead technician Kerry Kouchi, RPSGT. “I tell patients it’s like a Band-Aid; you put it on and you can feel it, but then later you forget it’s there.”

Vinh-Boi Nguyen, RPSGT, another lead technician at the center, says that although there have been some patients who were unable to fall asleep, “it’s really rare.”

“Some patients get their best night’s sleep here, especially because of the [CPAP/bilevel] treatment … or because they have bad sleep habits at home,” Nguyen says, adding that the center’s quiet environment and the elimination of TV can make it more conducive for sleeping than some patients’ home environments and sleep habits.

The electrode wires are a few feet long and are connected to a portable box, which allows a patient to be mobile when needed.

Besides setting up patients for the sleep study, the technicians often also have to spend time calming patients’ nerves.

“There’s sometimes an elevated level of anxiety coming to the lab: strange environment; strange people watching you sleep,” Kouchi says.

Eventually, no matter how many monitoring devices they are wearing or how nervous they are, the patients usually do end up falling asleep.

“Sleep is overwhelming; it’s like breathing—you can’t not do it,” Lenik says. “It’s a physiologic drive.”

While patients can go to bed at whatever time they prefer, the staff prefers that patients go to bed by 11 pm, because the technicians need at least a 6-hour sleep period—and actually prefer 8 hours—to make a proper analysis of the test. The technicians take a baseline at about 2 hours and then monitor a few hours of treatment with the CPAP equipment.

During sleep studies, the technicians are situated in the center’s control room to monitor the patients via the audio and video equipment, and the electrodes—making it impossible for patients to pretend to be asleep.

“You can’t fool the brain,” Kouchi says. “We know when you’re sleeping and when you’re awake. “

“I know it appears [that the technicians] just stare at the screen all the time, but that’s not what they do,” Lenik says. “They analyze what’s going on, and they need to stay sharp to do that. There’s no physician at night to discuss the case with, so they need to be able to know how to take care of any problems with the patient and how to adjust the [CPAP] levels when needed. They need to know the questions to ask the patient and what to look for when there’s a problem.”

When analyzing data from sleep studies, the technicians on staff check for breathing disorders, levels of snoring, cardiac arrhythmias, leg kicks, oxygen desaturation, and awakenings or arousals. One sleep study can comprise 800 to 1,000 pages of computer data.

“We look at every single page, and if there’s something unusual, we mark it, including what stage of sleep it was,” Kouchi says.

Analysis of a sleep test can take a few hours, since the technicians review every 30 seconds at a time, and go over it three or four times.

Stephen E. Brown, MD, pulmonologist and board-certified sleep specialist, reviews all of the technicians’ analyses and submits a final report with his findings and suggested treatment to the referring physician.

Those final reports help to educate physicians and their patients about the seriousness of sleep disorders and the treatment options available.

“We want people to understand what’s wrong with them, how bad it is, and what they can do about it. Whatever we find, we can probably treat. That’s the good news,” Lenik says.

Danielle Cohen is a staff writer for RT.