Dr. Shyam Subramanian, FCCP

Sleep Medicine

Survey results

Last year, the Sleep Medicine NetWork sent out a survey to its members to explore their relative comfort in managing different types of patients who may be seen in practice and the degree to which they encouraged referral of such patients to their practices. Though one could certainly debate the validity of the measurement tool, there were two main goals in collecting these data: we were hoping to debunk the commonly propagated myth that pulmonary sleep specialists \""only like to manage apnea\"" and that we are also planning on developing sessions at the CHEST meeting to focus on those areas in which are members were least comfortable.

One hundred and fifty NetWork members responded to the survey. Unsurprisingly, 93% reported that they were extremely comfortable managing obstructive sleep apnea; but we were surprised to see that the next most \""comfortable\"" area was restless legs syndrome, followed by central sleep apnea, and circadian rhythm disorders. Narcolepsy, parasomnias, insomnia, and management of the psychiatric patient with sleep problems rounded out the list. Based upon these data, the steering committee is planning a broader slate of sleep-related educational opportunities at CHEST 2013, with focus on some of the areas identified by our membership as areas in which they were less comfortable.

The steering committee has also started an online journal club, available through the College\'’s e-Community. Each month, one of our members will post a brief commentary on a recent sleep medicine publication. The conversation has been robust, and we hope you will join in!

Dr. David Schulman, FCCP

Chair

Occupational and Environmental Health

Course coming in June

From respiratory health hazards in the home and workplace to outdoor air pollution and global warming, the Occupational and Environmental Lung Disease Conference 2013 will cover everything you need to know about respiratory exposures and their effects on human health. Hear the most important new knowledge in the field and the clinical updates essential for patient care. This targeted intensive educational immersion in occupational and environmental lung diseases is a ""can’’t miss"" course for pulmonary clinicians and others. This multiday conference will bring together an expert faculty of educators and investigators. The last time this course was held was in 1999 – so don’’t miss this one! Go to the College’’s website to find all the information you need about this course in Toronto, Canada, on June 21-23. Register today!

Dr. Ware Kuschner, FCCP

Palliative and End-of-Life Care

How to make ethics consultations in hospitals more helpful and accessible

The practice of hospital clinical ethics is maturing. From the earliest days of hospital ethics committees to today (Rothman. Strangers at the Bedside, 2003), the practice of hospital clinical ethics consultation (CEC) has become ubiquitous (Fox et al. Am J Bioethics. 2007;7[2]:13; Hurst et al. Health Care Annal. 2007;15[4]:321; Nagao et al. BMC Med Ethics. 2008;29[9]:2). Currently, most hospitals have ethics committees that perform consultations.

Physicians do not call ethics consultations for many reasons:they They take too much time, might make the situation worse, or will be unqualified (DuVal et al. J Gen Intern Med. 2004;19:251). These published data are inconsistent with the authors’’ experience, as we consult on over 300 cases annually, but are consistent with what physicians elsewhere report. At the North American Burn Society meeting in January,, b, ,urn surgeons said they did not typically call consults because they did not find them helpful; and when they did, the services were not available in a timely fashion. So what is the problem?

The problem, we think, is a result of how the whole field of clinical ethics has evolved. The ""facilitative"" model has dominated (ASBH Core Competencies, volume 2). One might muse that if there haven’’t been qualified clinical ethicists, then simply facilitating the relevant parties in coming to their own recommendations was prudent. But today we know what a qualified clinical ethicist looks like (Acres et al. J Clin Ethics. 2012;23[2]:156) and what processes are needed to hire one (Mokwunye et al. HEC Forum. 2010;22[1]:51). Hospitals need to stop relying completely on ethics committee members, the vast majority of whom are untrained volunteers.

Instead, hospitals need to start building clinical ethics programs, just as they do other specialty group programs (such as behavioral medicine and heart failure groups). Just hiring one qualified clinical ethicist would allow for training for the ethics committee (Edelstein et al. HEC Forum. 2009;21[4]:34; Mokwunye et al. HEC Forum. 2012;23[2]:147), hospital-wide ethics education, and the establishment of upstream clinical ethics practices (DeRenzo et al. Cambridge Quarterly of Healthcare Ethics. 2006;15[2]:207). Once a hospital makes these changes, physicians will find they have better access to a helpful, full-service clinical ethics program that provides timely consultative services.

Dr. Nneka O. Mokwunye

Steering Committee Member

Dr. Evan G. DeRenzo

Respiratory Care

Unique liaisons

Did you know this NetWork has unique liaisons from the ACCP community?

Here is a brief description of these organizations with their liaisons from the ACCP:

AARC-BOMA: American Association for Respiratory Care – Board of Medical Advisors (www.aarc.org/)

The AARC is an association for respiratory care professionals and allied health specialists interested in cardiopulmonary care. The AARC is committed to enhancing professionalism of respiratory care practitioners, improving job performance, and helping to broaden the practitioners’’ scope of knowledge. The AARC publishes AARC Times and RESPIRATORY CARE.

AARC-BOMA Liaisons: Dr. Robert Aranson, FCCP; Dr. Kent L. Christopher, RRT, FCCP; Dr. Woody V. Kageler, FCCP; and Dr. Harold Manning, FCCP.

CoARC: Commission on Accreditation for Respiratory Care (www.coarc.com/)

CoARC’’s mission is to promote high quality respiratory care education through accreditation services. The CoARC accredits first professional respiratory care degree programs at the Associate, Baccalaureate, and Master Degree level in the United States and internationally and also accredits professional respiratory care degree programs in polysomnography.

CoARC Liaisons: Dr. David L. Bowton, FCCP; Dr. Joseph P. Coyle, FCCP; and Dr. Kevin M. O’’Neil, FCCP.

NAMDRC: The National Association for Medical Direction of Respiratory Care (www.namdrc.org/)

NAMDRC is a national organization of physicians whose mission is to educate its members and address regulatory, legislative, and payment issues that relate to the delivery of health care to patients with respiratory disorders. NAMDRC represents physicians in respiratory care departments, critical/ICUs, sleep labs, pulmonary rehabilitation, and managing blood gas laboratories. NAMDRC publishes Washington Watchline and Current Controversies.

NAMDRC has a representative to the ACCP Respiratory Care NetWork: Dr. Paul A. Selecky, FCCP.

NBRC: The National Board for Respiratory Care (www.nbrc.org)

The NBRC is a voluntary health certifying board that evaluates the professional competence of respiratory therapists. The NBRC strives for excellence in providing credentialing examinations and associated services to the respiratory community. The NBRC’’s CRT examination is currently the basis for state licensure for RTs in 49 states. Through its Continuing Competency Program, the NBRC demonstrates compliance with the accreditation standards of the National Commission for Certifying Agencies (NCCA).

NBRC Liaisons: Dr. Robert A. Balk, FCCP; Dr. Brian W. Carlin, FCCP (also the current NBRC Vice President); Dr. David A. Kaminsky, FCCP; Dr. Carl Kaplan, FCCP; and Dr. Robert A. May, FCCP.

Dr. Herbert Patrick, FCCP

Chair

Dr. Kevin M. O\'’Neil, FCCP

Vice-Chair

Home Care

Home sleep testing

The field of sleep medicine is evolving in multiple ways. One critical change involves the growing, and increasingly mandated, adoption of home sleep testing (HST) for the diagnosis of obstructive sleep apnea (OSA). While the technology is not new, its role in the routine diagnosis of OSA has evolved over the past decade. In a comprehensive review in 2003 by the ATS, AASM, and ACCP, HST was considered acceptable when attended, but its widespread use discouraged. A decision by Medicare to approve HST as an acceptable diagnostic modality paved the way for a more widespread adoption of HST. Recent data emerged that seemed to suggest that HST has acceptable degree of specificity and sensitivity in diagnosing OSA, but it was also clear that such results were seen only in a carefully selected and circumscribed population of patients without significant comorbidity and with high pretest probability of OSA. The broader applicability of such results is hence unclear. Advantages to HST are convenience, better patient acceptance, low barrier to deployment, and lower cost. Disadvantages include data loss, a large percentage of indeterminate study results, misdiagnosis – both false-positive and false-negative, and finally, inability to determine effects on sleep architecture, as well as diagnose comorbid sleep conditions. Important concerns regarding HST have been raised that include the lack of large outcome studies and lack of external validity. The cost effectiveness of a strategy that largely adopts HST as a diagnostic modality has also been questioned.

A clinical guidelines paper by the AASM portable monitoring task force highlights the limitations and contraindications of HST. The key elements include selecting patients with high pretest probability and excluding patients with moderate to severe pulmonary disease, neuromuscular disease, and congestive heart failure, or when other sleep disorders are either suspected or comorbid.

Issues to consider as one incorporates an HST strategy include selecting the appropriate equipment and outlining an appropriate triage and distribution plan that includes an appropriate chain of custody. A recent paper from the AASM, published in the Journal of Clinical Sleep Medicine, categorizes the different systems on the basis of a SCOPER system, to enable a ready comparison of the features across different systems. Factors that need to be considered would include costs, not only of the equipment itself, but more importantly of the disposables, as well as data management and software integration with your existing platform.

Dr. Shyam Subramanian, FCCP

Vice-Chair

Selected References:

1. Collop NA, Tracy SL, Kapur V, et al. Obstructive sleep apnea devices for out-of-center (OOC) testing: technology evaluation. J Clin Sleep Med. 2011;7(5):531.

2. Pietzsch JB, Garner A, Cipriano LE, Linehan JH. An integrated health-economic analysis of diagnostic and therapeutic strategies in the treatment of moderate-to-severe obstructive sleep apnea. Sleep. 2011;34(6):695.

3. Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med. 2007;3(7):737.

Dr. Shyam Subramanian, FCCP

Vice-Chair

NetWork members: Join the conversation in the ACCP e-Community today! http://Find us at ecommunity.chestnet.org.

Sleep Medicine

Survey results

Last year, the Sleep Medicine NetWork sent out a survey to its members to explore their relative comfort in managing different types of patients who may be seen in practice and the degree to which they encouraged referral of such patients to their practices. Though one could certainly debate the validity of the measurement tool, there were two main goals in collecting these data: we were hoping to debunk the commonly propagated myth that pulmonary sleep specialists \""only like to manage apnea\"" and that we are also planning on developing sessions at the CHEST meeting to focus on those areas in which are members were least comfortable.

One hundred and fifty NetWork members responded to the survey. Unsurprisingly, 93% reported that they were extremely comfortable managing obstructive sleep apnea; but we were surprised to see that the next most \""comfortable\"" area was restless legs syndrome, followed by central sleep apnea, and circadian rhythm disorders. Narcolepsy, parasomnias, insomnia, and management of the psychiatric patient with sleep problems rounded out the list. Based upon these data, the steering committee is planning a broader slate of sleep-related educational opportunities at CHEST 2013, with focus on some of the areas identified by our membership as areas in which they were less comfortable.

The steering committee has also started an online journal club, available through the College\'’s e-Community. Each month, one of our members will post a brief commentary on a recent sleep medicine publication. The conversation has been robust, and we hope you will join in!

Dr. David Schulman, FCCP

Chair

Occupational and Environmental Health

Course coming in June

From respiratory health hazards in the home and workplace to outdoor air pollution and global warming, the Occupational and Environmental Lung Disease Conference 2013 will cover everything you need to know about respiratory exposures and their effects on human health. Hear the most important new knowledge in the field and the clinical updates essential for patient care. This targeted intensive educational immersion in occupational and environmental lung diseases is a ""can’’t miss"" course for pulmonary clinicians and others. This multiday conference will bring together an expert faculty of educators and investigators. The last time this course was held was in 1999 – so don’’t miss this one! Go to the College’’s website to find all the information you need about this course in Toronto, Canada, on June 21-23. Register today!

Dr. Ware Kuschner, FCCP

Palliative and End-of-Life Care

How to make ethics consultations in hospitals more helpful and accessible

The practice of hospital clinical ethics is maturing. From the earliest days of hospital ethics committees to today (Rothman. Strangers at the Bedside, 2003), the practice of hospital clinical ethics consultation (CEC) has become ubiquitous (Fox et al. Am J Bioethics. 2007;7[2]:13; Hurst et al. Health Care Annal. 2007;15[4]:321; Nagao et al. BMC Med Ethics. 2008;29[9]:2). Currently, most hospitals have ethics committees that perform consultations.

Physicians do not call ethics consultations for many reasons:they They take too much time, might make the situation worse, or will be unqualified (DuVal et al. J Gen Intern Med. 2004;19:251). These published data are inconsistent with the authors’’ experience, as we consult on over 300 cases annually, but are consistent with what physicians elsewhere report. At the North American Burn Society meeting in January,, b, ,urn surgeons said they did not typically call consults because they did not find them helpful; and when they did, the services were not available in a timely fashion. So what is the problem?

The problem, we think, is a result of how the whole field of clinical ethics has evolved. The ""facilitative"" model has dominated (ASBH Core Competencies, volume 2). One might muse that if there haven’’t been qualified clinical ethicists, then simply facilitating the relevant parties in coming to their own recommendations was prudent. But today we know what a qualified clinical ethicist looks like (Acres et al. J Clin Ethics. 2012;23[2]:156) and what processes are needed to hire one (Mokwunye et al. HEC Forum. 2010;22[1]:51). Hospitals need to stop relying completely on ethics committee members, the vast majority of whom are untrained volunteers.

Instead, hospitals need to start building clinical ethics programs, just as they do other specialty group programs (such as behavioral medicine and heart failure groups). Just hiring one qualified clinical ethicist would allow for training for the ethics committee (Edelstein et al. HEC Forum. 2009;21[4]:34; Mokwunye et al. HEC Forum. 2012;23[2]:147), hospital-wide ethics education, and the establishment of upstream clinical ethics practices (DeRenzo et al. Cambridge Quarterly of Healthcare Ethics. 2006;15[2]:207). Once a hospital makes these changes, physicians will find they have better access to a helpful, full-service clinical ethics program that provides timely consultative services.

Dr. Nneka O. Mokwunye

Steering Committee Member

Dr. Evan G. DeRenzo

Respiratory Care

Unique liaisons

Did you know this NetWork has unique liaisons from the ACCP community?

Here is a brief description of these organizations with their liaisons from the ACCP:

AARC-BOMA: American Association for Respiratory Care – Board of Medical Advisors (www.aarc.org/)

The AARC is an association for respiratory care professionals and allied health specialists interested in cardiopulmonary care. The AARC is committed to enhancing professionalism of respiratory care practitioners, improving job performance, and helping to broaden the practitioners’’ scope of knowledge. The AARC publishes AARC Times and RESPIRATORY CARE.

AARC-BOMA Liaisons: Dr. Robert Aranson, FCCP; Dr. Kent L. Christopher, RRT, FCCP; Dr. Woody V. Kageler, FCCP; and Dr. Harold Manning, FCCP.

CoARC: Commission on Accreditation for Respiratory Care (www.coarc.com/)

CoARC’’s mission is to promote high quality respiratory care education through accreditation services. The CoARC accredits first professional respiratory care degree programs at the Associate, Baccalaureate, and Master Degree level in the United States and internationally and also accredits professional respiratory care degree programs in polysomnography.

CoARC Liaisons: Dr. David L. Bowton, FCCP; Dr. Joseph P. Coyle, FCCP; and Dr. Kevin M. O’’Neil, FCCP.

NAMDRC: The National Association for Medical Direction of Respiratory Care (www.namdrc.org/)

NAMDRC is a national organization of physicians whose mission is to educate its members and address regulatory, legislative, and payment issues that relate to the delivery of health care to patients with respiratory disorders. NAMDRC represents physicians in respiratory care departments, critical/ICUs, sleep labs, pulmonary rehabilitation, and managing blood gas laboratories. NAMDRC publishes Washington Watchline and Current Controversies.

NAMDRC has a representative to the ACCP Respiratory Care NetWork: Dr. Paul A. Selecky, FCCP.

NBRC: The National Board for Respiratory Care (www.nbrc.org)

The NBRC is a voluntary health certifying board that evaluates the professional competence of respiratory therapists. The NBRC strives for excellence in providing credentialing examinations and associated services to the respiratory community. The NBRC’’s CRT examination is currently the basis for state licensure for RTs in 49 states. Through its Continuing Competency Program, the NBRC demonstrates compliance with the accreditation standards of the National Commission for Certifying Agencies (NCCA).

NBRC Liaisons: Dr. Robert A. Balk, FCCP; Dr. Brian W. Carlin, FCCP (also the current NBRC Vice President); Dr. David A. Kaminsky, FCCP; Dr. Carl Kaplan, FCCP; and Dr. Robert A. May, FCCP.

Dr. Herbert Patrick, FCCP

Chair

Dr. Kevin M. O\'’Neil, FCCP

Vice-Chair

Home Care

Home sleep testing

The field of sleep medicine is evolving in multiple ways. One critical change involves the growing, and increasingly mandated, adoption of home sleep testing (HST) for the diagnosis of obstructive sleep apnea (OSA). While the technology is not new, its role in the routine diagnosis of OSA has evolved over the past decade. In a comprehensive review in 2003 by the ATS, AASM, and ACCP, HST was considered acceptable when attended, but its widespread use discouraged. A decision by Medicare to approve HST as an acceptable diagnostic modality paved the way for a more widespread adoption of HST. Recent data emerged that seemed to suggest that HST has acceptable degree of specificity and sensitivity in diagnosing OSA, but it was also clear that such results were seen only in a carefully selected and circumscribed population of patients without significant comorbidity and with high pretest probability of OSA. The broader applicability of such results is hence unclear. Advantages to HST are convenience, better patient acceptance, low barrier to deployment, and lower cost. Disadvantages include data loss, a large percentage of indeterminate study results, misdiagnosis – both false-positive and false-negative, and finally, inability to determine effects on sleep architecture, as well as diagnose comorbid sleep conditions. Important concerns regarding HST have been raised that include the lack of large outcome studies and lack of external validity. The cost effectiveness of a strategy that largely adopts HST as a diagnostic modality has also been questioned.

A clinical guidelines paper by the AASM portable monitoring task force highlights the limitations and contraindications of HST. The key elements include selecting patients with high pretest probability and excluding patients with moderate to severe pulmonary disease, neuromuscular disease, and congestive heart failure, or when other sleep disorders are either suspected or comorbid.

Issues to consider as one incorporates an HST strategy include selecting the appropriate equipment and outlining an appropriate triage and distribution plan that includes an appropriate chain of custody. A recent paper from the AASM, published in the Journal of Clinical Sleep Medicine, categorizes the different systems on the basis of a SCOPER system, to enable a ready comparison of the features across different systems. Factors that need to be considered would include costs, not only of the equipment itself, but more importantly of the disposables, as well as data management and software integration with your existing platform.

Dr. Shyam Subramanian, FCCP

Vice-Chair

Selected References:

1. Collop NA, Tracy SL, Kapur V, et al. Obstructive sleep apnea devices for out-of-center (OOC) testing: technology evaluation. J Clin Sleep Med. 2011;7(5):531.

2. Pietzsch JB, Garner A, Cipriano LE, Linehan JH. An integrated health-economic analysis of diagnostic and therapeutic strategies in the treatment of moderate-to-severe obstructive sleep apnea. Sleep. 2011;34(6):695.

3. Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med. 2007;3(7):737.

Dr. Shyam Subramanian, FCCP

Vice-Chair

NetWork members: Join the conversation in the ACCP e-Community today! http://Find us at ecommunity.chestnet.org.

Sleep Medicine

Survey results

Last year, the Sleep Medicine NetWork sent out a survey to its members to explore their relative comfort in managing different types of patients who may be seen in practice and the degree to which they encouraged referral of such patients to their practices. Though one could certainly debate the validity of the measurement tool, there were two main goals in collecting these data: we were hoping to debunk the commonly propagated myth that pulmonary sleep specialists \""only like to manage apnea\"" and that we are also planning on developing sessions at the CHEST meeting to focus on those areas in which are members were least comfortable.

One hundred and fifty NetWork members responded to the survey. Unsurprisingly, 93% reported that they were extremely comfortable managing obstructive sleep apnea; but we were surprised to see that the next most \""comfortable\"" area was restless legs syndrome, followed by central sleep apnea, and circadian rhythm disorders. Narcolepsy, parasomnias, insomnia, and management of the psychiatric patient with sleep problems rounded out the list. Based upon these data, the steering committee is planning a broader slate of sleep-related educational opportunities at CHEST 2013, with focus on some of the areas identified by our membership as areas in which they were less comfortable.

The steering committee has also started an online journal club, available through the College\'’s e-Community. Each month, one of our members will post a brief commentary on a recent sleep medicine publication. The conversation has been robust, and we hope you will join in!

Dr. David Schulman, FCCP

Chair

Occupational and Environmental Health

Course coming in June

From respiratory health hazards in the home and workplace to outdoor air pollution and global warming, the Occupational and Environmental Lung Disease Conference 2013 will cover everything you need to know about respiratory exposures and their effects on human health. Hear the most important new knowledge in the field and the clinical updates essential for patient care. This targeted intensive educational immersion in occupational and environmental lung diseases is a ""can’’t miss"" course for pulmonary clinicians and others. This multiday conference will bring together an expert faculty of educators and investigators. The last time this course was held was in 1999 – so don’’t miss this one! Go to the College’’s website to find all the information you need about this course in Toronto, Canada, on June 21-23. Register today!

Dr. Ware Kuschner, FCCP

Palliative and End-of-Life Care

How to make ethics consultations in hospitals more helpful and accessible

The practice of hospital clinical ethics is maturing. From the earliest days of hospital ethics committees to today (Rothman. Strangers at the Bedside, 2003), the practice of hospital clinical ethics consultation (CEC) has become ubiquitous (Fox et al. Am J Bioethics. 2007;7[2]:13; Hurst et al. Health Care Annal. 2007;15[4]:321; Nagao et al. BMC Med Ethics. 2008;29[9]:2). Currently, most hospitals have ethics committees that perform consultations.

Physicians do not call ethics consultations for many reasons:they They take too much time, might make the situation worse, or will be unqualified (DuVal et al. J Gen Intern Med. 2004;19:251). These published data are inconsistent with the authors’’ experience, as we consult on over 300 cases annually, but are consistent with what physicians elsewhere report. At the North American Burn Society meeting in January,, b, ,urn surgeons said they did not typically call consults because they did not find them helpful; and when they did, the services were not available in a timely fashion. So what is the problem?

The problem, we think, is a result of how the whole field of clinical ethics has evolved. The ""facilitative"" model has dominated (ASBH Core Competencies, volume 2). One might muse that if there haven’’t been qualified clinical ethicists, then simply facilitating the relevant parties in coming to their own recommendations was prudent. But today we know what a qualified clinical ethicist looks like (Acres et al. J Clin Ethics. 2012;23[2]:156) and what processes are needed to hire one (Mokwunye et al. HEC Forum. 2010;22[1]:51). Hospitals need to stop relying completely on ethics committee members, the vast majority of whom are untrained volunteers.

Instead, hospitals need to start building clinical ethics programs, just as they do other specialty group programs (such as behavioral medicine and heart failure groups). Just hiring one qualified clinical ethicist would allow for training for the ethics committee (Edelstein et al. HEC Forum. 2009;21[4]:34; Mokwunye et al. HEC Forum. 2012;23[2]:147), hospital-wide ethics education, and the establishment of upstream clinical ethics practices (DeRenzo et al. Cambridge Quarterly of Healthcare Ethics. 2006;15[2]:207). Once a hospital makes these changes, physicians will find they have better access to a helpful, full-service clinical ethics program that provides timely consultative services.

Dr. Nneka O. Mokwunye

Steering Committee Member

Dr. Evan G. DeRenzo

Respiratory Care

Unique liaisons

Did you know this NetWork has unique liaisons from the ACCP community?

Here is a brief description of these organizations with their liaisons from the ACCP:

AARC-BOMA: American Association for Respiratory Care – Board of Medical Advisors (www.aarc.org/)

The AARC is an association for respiratory care professionals and allied health specialists interested in cardiopulmonary care. The AARC is committed to enhancing professionalism of respiratory care practitioners, improving job performance, and helping to broaden the practitioners’’ scope of knowledge. The AARC publishes AARC Times and RESPIRATORY CARE.

AARC-BOMA Liaisons: Dr. Robert Aranson, FCCP; Dr. Kent L. Christopher, RRT, FCCP; Dr. Woody V. Kageler, FCCP; and Dr. Harold Manning, FCCP.

CoARC: Commission on Accreditation for Respiratory Care (www.coarc.com/)

CoARC’’s mission is to promote high quality respiratory care education through accreditation services. The CoARC accredits first professional respiratory care degree programs at the Associate, Baccalaureate, and Master Degree level in the United States and internationally and also accredits professional respiratory care degree programs in polysomnography.

CoARC Liaisons: Dr. David L. Bowton, FCCP; Dr. Joseph P. Coyle, FCCP; and Dr. Kevin M. O’’Neil, FCCP.

NAMDRC: The National Association for Medical Direction of Respiratory Care (www.namdrc.org/)

NAMDRC is a national organization of physicians whose mission is to educate its members and address regulatory, legislative, and payment issues that relate to the delivery of health care to patients with respiratory disorders. NAMDRC represents physicians in respiratory care departments, critical/ICUs, sleep labs, pulmonary rehabilitation, and managing blood gas laboratories. NAMDRC publishes Washington Watchline and Current Controversies.

NAMDRC has a representative to the ACCP Respiratory Care NetWork: Dr. Paul A. Selecky, FCCP.

NBRC: The National Board for Respiratory Care (www.nbrc.org)

The NBRC is a voluntary health certifying board that evaluates the professional competence of respiratory therapists. The NBRC strives for excellence in providing credentialing examinations and associated services to the respiratory community. The NBRC’’s CRT examination is currently the basis for state licensure for RTs in 49 states. Through its Continuing Competency Program, the NBRC demonstrates compliance with the accreditation standards of the National Commission for Certifying Agencies (NCCA).

NBRC Liaisons: Dr. Robert A. Balk, FCCP; Dr. Brian W. Carlin, FCCP (also the current NBRC Vice President); Dr. David A. Kaminsky, FCCP; Dr. Carl Kaplan, FCCP; and Dr. Robert A. May, FCCP.

Dr. Herbert Patrick, FCCP

Chair

Dr. Kevin M. O\'’Neil, FCCP

Vice-Chair

Home Care

Home sleep testing

The field of sleep medicine is evolving in multiple ways. One critical change involves the growing, and increasingly mandated, adoption of home sleep testing (HST) for the diagnosis of obstructive sleep apnea (OSA). While the technology is not new, its role in the routine diagnosis of OSA has evolved over the past decade. In a comprehensive review in 2003 by the ATS, AASM, and ACCP, HST was considered acceptable when attended, but its widespread use discouraged. A decision by Medicare to approve HST as an acceptable diagnostic modality paved the way for a more widespread adoption of HST. Recent data emerged that seemed to suggest that HST has acceptable degree of specificity and sensitivity in diagnosing OSA, but it was also clear that such results were seen only in a carefully selected and circumscribed population of patients without significant comorbidity and with high pretest probability of OSA. The broader applicability of such results is hence unclear. Advantages to HST are convenience, better patient acceptance, low barrier to deployment, and lower cost. Disadvantages include data loss, a large percentage of indeterminate study results, misdiagnosis – both false-positive and false-negative, and finally, inability to determine effects on sleep architecture, as well as diagnose comorbid sleep conditions. Important concerns regarding HST have been raised that include the lack of large outcome studies and lack of external validity. The cost effectiveness of a strategy that largely adopts HST as a diagnostic modality has also been questioned.

A clinical guidelines paper by the AASM portable monitoring task force highlights the limitations and contraindications of HST. The key elements include selecting patients with high pretest probability and excluding patients with moderate to severe pulmonary disease, neuromuscular disease, and congestive heart failure, or when other sleep disorders are either suspected or comorbid.

Issues to consider as one incorporates an HST strategy include selecting the appropriate equipment and outlining an appropriate triage and distribution plan that includes an appropriate chain of custody. A recent paper from the AASM, published in the Journal of Clinical Sleep Medicine, categorizes the different systems on the basis of a SCOPER system, to enable a ready comparison of the features across different systems. Factors that need to be considered would include costs, not only of the equipment itself, but more importantly of the disposables, as well as data management and software integration with your existing platform.

Dr. Shyam Subramanian, FCCP

Vice-Chair

Selected References:

1. Collop NA, Tracy SL, Kapur V, et al. Obstructive sleep apnea devices for out-of-center (OOC) testing: technology evaluation. J Clin Sleep Med. 2011;7(5):531.

2. Pietzsch JB, Garner A, Cipriano LE, Linehan JH. An integrated health-economic analysis of diagnostic and therapeutic strategies in the treatment of moderate-to-severe obstructive sleep apnea. Sleep. 2011;34(6):695.

3. Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med. 2007;3(7):737.

Dr. Shyam Subramanian, FCCP

Vice-Chair

NetWork members: Join the conversation in the ACCP e-Community today! http://Find us at ecommunity.chestnet.org.