Cardio Sleep Review

Dedicated to the Nexus of Cardiology and Sleep Apnea Management

Issue 2,
November
2018

Patients Appreciate the Value of Home Testing—From a Cardiologist with Sleep Apnea

by Dr. Rick Pumill, MD

A practicing cardiologist, Rick Pumill, MD, has “pretty severe” obstructive sleep apnea. That may be why he has a great interest in the condition that affects one in five adults than other cardiologists.


Dr. Rick Pumill, MD

Science has proven a direct correlation between sleep apnea and some of the heart conditions that Dr. Pumill sees every day in his busy practice including hypertension, atrial fibrillation, and congestive heart failure. It’s virtually impossible to treat cardiac disease without treating their underlying sleep apnea. “That’s why, if we don’t diagnose sleep apnea and treat it if it’s found, we are doing a great disservice to our patients,” he said during a recent interview.

Dr. Pumill’s practice is a referral practice. “Patients who come to see me are sent by someone else either because they are not getting better or their current treating physician needs subspecialty input to better manage their heart care,” Dr. Pumill explained. He finds that patients generally listen “to me because, by the time they get to me, they are scared they are going to die or had a family member die of heart disease. Still, getting them to go for that sleep test overnight in a sleep lab has always been a challenge.”

Not only are patients reluctant, he said, but it’s also time-consuming to get the necessary insurance approvals and difficult to get the test scheduled. Adding to the scheduling problem is the fact that the lab may only be open evenings. “By the time you get everything you need, it can easily take two months or more,”.

Compliance for sleep testing is extremely low. The patients just don’t follow up as often as they should. Pumill adds that it’s not unusual for patients to come back to his office for follow-up visits months later only to learn they never went for their sleep lab test. Or if they did go, they never got the results. “Again, because the sleep lab isn’t open during the day, even if they went for the study, tracking down the results, is not easy either,” he said.

Cost is also a factor, Dr. Pumill notes. Sleep studies performed in a lab are extremely expensive, sometimes in the thousands of dollars, with large components generally an out of pocket expense.

HOME SLEEP TESTING CHANGING THE LANDSCAPE

Being able to send patients he suspects may have sleep apnea home the same day as the office consultation with sleep-testing devices like the WatchPAT® has changed his practice considerably and definitely for the better, he said.

Dr. Pumill decides whether patients should be tested for sleep apnea by talking with them and their bed partners. “I don’t use questionnaires,” he said. He also looks for physical signs including an abnormal EKG showing enlargement of the right side of the heart. “That’s a tipoff,” he said. Also, he said, if he sees someone who has atrial fibrillation, “it’s something to think about. If I see someone with refractory hypertension, it’s something to think about. And if I see someone who is obese, it’s something to think about.” Another hint: The patient has a round face, a small mouth and a 17- inch or greater neck like he does. That anatomy is an obvious sign, said Dr. Pumill, who blames these anatomical features for his sleep apnea. At 5’10” and 180 pounds, obesity isn’t his issue, he said with a laugh.

“If we don’t diagnose sleep apnea and treat it if it’s found, we are doing a great disservice to our patients.”

Unless Dr. Pumill suspects the patient has a serious heart condition that requires testing in a sleep lab, he sends the patient home with a WatchPAT®. What he likes about home sleep testing is the ease of doing it, the immediacy of the results, and high patient compliance.

When he sends patients home with the sleep test, patients use it that evening. The patients or their surrogates bring their devices back to the office the next day. Reaction time is quick, Dr. Pumill said. “We get the results and, if they do have sleep apnea, we contact the durable medical supply company near them and set them up with a CPAP machine all within 72 hours.”

Dr. Pumill explains to his patients how easy home testing is with the WatchPAT®. “I tell patients that the home-testing device is very user-friendly and comfortable. I find they are able to use it properly with no trouble at all. And they don’t have to leave their house.”

When he gets the results, Dr. Pumill consults with the physician who treats his own sleep apnea to determine the best course of treatment.

The cost of home testing, at around $200, is a wonderful bonus, especially when compared to a sleep lab test, Dr. Pumill noted. Many patients today have high-deductible insurance plans and may have to pay as much as $6,000 out-of-pocket, so they’re grateful that they can do sleep testing at home for far less. Insurance companies also are more likely to approve a home sleep test than a lab study test for that reason.

“If they go for sleep testing and need a CPAP and get it before their surgery, it’s a much safer recovery when they come home after their operation.”

Dr. Pumill can point to at least two patients he has seen recently where home sleep testing was invaluable. “One patient came to see me for chest pain that started after he was in a car accident,” he said. The patient was driving with his son and stopped at a red light. He fell asleep and accidentally stepped on the gas, striking a parked car. His chest went into the steering wheel when it happened. “When he told me he fell asleep at the wheel, I suspected sleep apnea and sent him home with a sleep testing device,” Dr. Pumill recalled. The WatchPAT® data indicated that the patient did have severe sleep apnea. Because the patient had an abnormal EKG, Dr. Pumill ordered a stress test and saw he had coexisting coronary artery disease, which he also treated. “But we wouldn’t have found that he had sleep apnea unless we did the testing. It was critical to his overall care and getting a good outcome, as well as a safety factor since the patient had been falling asleep at the wheel for years,” Dr. Pumill said.

Another patient Dr. Pumill had was on CPAP for years and thought he was doing quite well, Dr. Pumill said. However, the patient was still tired all the time and his blood pressure was poorly controlled. “I convinced him to use the WatchPAT®, which he could attach even if he was sleeping with his CPAP mask,” Dr. Pumill said. “The beauty of the WatchPAT® is you can do it while you’re wearing your CPAP.” The study showed the patient had an AHI of 17 despite using his nasal mask, but he wasn’t using the chin strap from his machine and so the CPAP wasn’t effective. “We wouldn’t have learned the source of the problem without the WatchPAT®,” Dr. Pumill said.

CPAP IS STANDARD OF CARE FOR OSA

Dr. Pumill believes that CPAP is the best treatment for obstructive sleep apnea in most cases. (Mandibular devices are effective in a small group of people, as is positional therapy he noted. And a new pacemaker-like device has recently become available for people unable to tolerate CPAP therapy.) However, Dr. Pumill knows many patients are reluctant to use a CPAP machine, fearing it’s cumbersome and makes sleeping difficult. Here’s another example where his personal experience comes into play. Dr. Pumill uses a CPAP for his own sleep apnea. “I don’t hesitate to tell them about my experience with CPAP and I find sometimes that can help, too,” Dr. Pumill said. Key to compliance is having the respiratory therapist from the durable medical goods company spend time with the patient learning their sleep habits and finding the most comfortable mask for them.

People who have OSA and however reluctantly go on CPAP often come back and tell me “it changed their life,” Dr. Pumill said. “And often it’s the same people who were fighting it and didn’t want to do it.”

If Dr. Pumill has a cardiology patient he suspects has sleep apnea and who requires surgery, he encourages them to have their sleep test before their surgery if at all possible. Communicating this information to the surgeon and anesthesiologist is also imperative. “If you have a patient who has surgery that’s going to cause more shallow breathing while they’re recovering, and if they’re on pain medication, it’s a setup for disaster,” Dr. Pumill said. “If they go for sleep testing and need a CPAP and get it before their surgery, it’s a much safer recovery when they come home after their operation.”

Dr. Pumill has been sending patients for sleep testing for years. “I sent my first patient about 25 years ago for a sleep study,” he said. Sleep studies are really not anything new, he adds. But as more is studied and written in the literature about the association between congestive heart failure, atrial fibrillation and other heart conditions and sleep apnea, “people are paying more attention to it,” he said. Thanks to home sleep testing devices sleep testing no longer has to be a big production nor take the patient away from his or her bed, Dr. Pumill said. Not only is this good news for patients but also for the doctors treating them.

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Cardio Sleep Review
Publisher: Itamar Medical
Editor: Melih Alvo

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