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Finding and Treating Sleep Apnea in Your Practice

Part 3 - What to look for when screening patients for sleep apnea continued

Dr. Kent Smith, DDS
Dr. Smith continues to discuss screening patients for sleep apnea using the Mallampati score.

Here's a pharyngeal grade. On the left is what we want our patient to look like. We called it the curtains. When I'm talking to a patients I say if your life was a play, the curtains are almost, if they get over here on the right, say level 4 if their pharyngeal grade is 3 or 4 they fall into our formula. I tell them the curtains are closing. This is not good. Your play is almost over. We need to do something. So pharyngeal grade 3 or 4 they fall into our formula. Here's a class 1. There's a class 2. There's a class 3. And there's a class 4. So you can see the curtains are closing further and further. That's what we called the horizontal measure. You may have heard of the Mallampati score, that's a vertical measure. So there's two different was to measure closure of the oral pharynx, the pharyngeal grade and the Mallampati. I personally think that the pharyngeal grade is more important. It's very difficult to measure the Mallampati because the tongue keeps rising up and down. It's hard to really visualize the back of the throat without manipulating it in some way and that's the way the Mallampati is scored. Showing how we use this formula. Here's a patient his BMI is 36. So he is considered obese. Anything 30 or higher is considered obese. His cricomental spaces 0. You can't tell from straight on like this but trust me he has no cricomental space. His pharyngeal grade is 4 and he's got an overbite. Okay. So his AHI happened to be 123. Extremely severe but he's CPAP intolerant. This patient should be on CPAP. When you stop breathing every 30 seconds for at least 10 seconds and I say at least 10 seconds. These patients actually stop breathing an average of 20 seconds. When you look at a study all night long, the average event last about 20 seconds. So this guy every 30 seconds stops breathing for 20 seconds. Then he breathes for 10, stops breathing for 20. I don't know how somebody like this makes it through the night. But he came in to see me. We've got him an appliance and we'll see. He really needs to have some reconstruction. Open up his vertical dimension and maybe to get some surgery to advance the jaws, all kinds of stuff, if he can't tolerate CPAP. So again if the cricomental space is less than 1.5 cm, if the pharyngeal grade is greater than 2, those curtains coming in and if they have an overbite, 95% of the time they have sleep apnea. But the only way we can really know is through sleep study. Don't even try to diagnose a patient like this. It's just called screening or prescreening. So how do we diagnose. There's two different ways. We've got polysomnography. It's called the PSG for short and that is done in a certified sleep lab or sleep center. Then we have home or ambulatory sleep lodgers. And there's various brands out there. I couldn't practice in my office without these units because many of our patients for whatever reason don't want to go to a sleep center. They have a sleep study down. I talk to them daily. There's patients after patients says I can't do that or perhaps they went to one in the past and they'll never do that again because it's sleeps in a foreign environment. It's really not considered as much of a gold standard as it used to be because the home unit has gotten so sophisticated they are almost as detail as the polysomnogram. But with the polysomnogram is called an attended study because you've got somebody that's watching the patient. And if a lead comes lose or something like that they can go in and make a correction and fix it. And they can measure a few more things than the home monitors can't. But the home monitors can be used to diagnose to sleep apnea, not by us. Again, it has to be diagnosed by sleep physician. This is what the remote monitoring looks like in a sleep center. She is looking at a little screen. She can see the patients. She can see if a lead falls off if the patient has to go to the bathroom or something like that. And she can score two different patients or sometimes even three but usually its two patients at the time as this scroll across her monitor she knows what stage sleeps they're in. She's really good at gauging these things. She marks it on the screen. She then turned this information over to the sleep physicians the next day who looked at the data as well. This is what the arrangement usually looks like. This is kind of like a freestanding sleep center. It's almost like a hotel room. You check in. They hook you up. You can watch TV. You can read a book. It's as comfortable as they can make it. These are free standing sleep centers. You can also create sleep centers in a hospital setting so in that situation it would look like a hospital room not as comfortable. But this is an ideal scenario for somebody that's going and having a sleep study an attended sleep study at a sleep center. But really what looks easier I mean sleeping in a sleep center with all these things hooked up to you. So you've got a female that you sent in for a sleep study. She goes in. She meets the sleep tech and he's a big guy. He's a got a muscle shirt on. He's got tattoos and he goes „Okay, sweetie, I'm going to hook you up to these leads and I'll be watching you all night all.‰ Not real conducive to a restful, peaceful night of sleep. So for that reason I'd like the home units. We use this, a lot. Now you can certainly treat these patients without home units. However, you will not get everybody screen properly in your practice if you do. I highly encourage you to get one. There's a bunch of good ones out there. I've got five different types in my practice. I probably use a Watch PAT more than any of them. That's the upper right one. There's nothing in the nose. There's no nasal cannula so it's a little more comfortable for the patient. Some sleep physicians don't like it because there's not a nasal cannula. But there are various reasons to use different types of monitor. And I use them all the time in our practice. We have I think 10 or 11 monitors and many times they're all out. We don't have one for the next patient that comes in. So you can tell we use them a lot. You do get paid to do these studies by the way. Not until about 2011 mid 2011 where we're getting paid to do sleep studies. But now when we send them in, not everybody, not every insurance company pay for this but we file everything to MediCal. And since they do pay for these studies now, the cost of the units are getting reimbursed. So it just makes sense to have these units in your practice now.