Sleep tech and New member

Hello everyone I am currently employed as a sleep technologist, and have had my registration since 2015. I just stumbled across this forum while searching for an insurance question regarding Tricare and hypopnea scoring and noticed the wealth of information it has to offer. I am also always happy to hear the viewpoints of cpap users who are not medical professionals and of their experiences with sleep apnea and the various PAP devices and mask. Anything I can learn that will help my future patients have more peace of mind would be great to have.

So my first question for everyone who has gone through a sleep study here. If you could sit down with the tech you had or various techs you have had, what would you ask them about now or ask them to do different next time. I would like to see if their is anything I am currently not doing that I should be.

Welcome to the forum.

I had the 2 traditional sleep studies done in a lab...diagnostic and the titration. Separate night because I didn't quite make criteria for split night.

The first tech...nice guy, like him but unfortunately the questions I asked or wanted to ask pertained to details that he really wasn't legally able to answer. I worked in the medical profession so I understand the limitation for medical legal reasons.

The second guy was the titration study. I have never had a more unpleasant experience with any procedure or medical personnel in all my life. I refer to it as the night from hell.
He would not listen to me about the mask and refused to let me try the nasal pillow mask for the titration and told me I HAD to use a full face mask and would listen when I told him that I simply can't wear anything on the nasal bridge.
So finally I told him give me a nasal pillow mask or I go home...simple as that.
What an asshole he was about it...told me how much I was going to mess up the test and how it would never work and was a general ass.

I got it done and even with one that was too big and then he says..."well to be honest you are the first person I have had want to do the titration with pillows. I didn't think it would work."

My first suggestion...listen to your patients and don't treat them like that are 2 year olds with no mind.
Some patients actually can have a rather extensive medical training and are far from stupid. To this day I still say if I was to ever see him in the crosswalk I would have a real hard time not wanting to run him over. Left a really bad taste in my mouth. The diagnostic tech...worth his weight in gold. He did answer my questions as best he could withing the medical legal restrictions.

Be honest...don't lie..that second guy...flat out lied to me about some stuff. Remember I had pre med in college and worked in the medical field for over 35 years....I wasn't the typical lay person patient but I sure got treated like crap and lied to. We had a really big laugh here at the forum over the whoppers I was told.

Question for you....do you know much about UARS?

First of all thank you for your reply Pugsy.

Second I am very sorry to hear of the treatment you received at the hands of the second technologist. Personally I generally love to have a medical patient because then I can go into even deeper detail on OSA and the entire hookup procedure. I try to never make assumptions about my patients based off appearance or initial thoughts. I went to school to be an EEG tech first and we were trained to always talk to the patients during hookup as their are things they may tell us but not the Dr. So I always chat throughout the hookup process, alternating between personal conversation and explaining the procedure in detail. Unless a patient flat just dose not want to talk I always have at least some idea about their background and skill set.

As for the mask I have used several full faces on patients when I worked in a hospital previously, and nasals as well. In the small practice I am at now I am using more nasals and then going to full face only if the leak or oral venting is an issue, or if the patient request. I will admit that personally I am not a great fan of pillows but that is because in my experience the straps are not as adjustable as FF and Nasal and it can be harder to prevent leakage. However I never deny a patient the right to try the mask type they want to use, unless flat ordered by the Dr.

Finally UARS, not enough I wish to say. Unfortunately the insurance companies don't care about UARS and so schooling barely touches the subject. I personally find this regrettable as their are many patients out their that need care and are being denied because they are not (sick enough) in the eyes of insurance. I am not sure if you know this or not but scoring critera of hypopneas for insurance companies is based off oxygen desaturation rate. Hypopneas used to be based strictly off a 3% drop in SaO2 along with wave drop and arousal as mandated by the AASM. However that is no longer the case and some insurances as well as all Medicaid and Medicare patients save for children are graded on a 4% drop only which means even if their is a clear 3% hypopnea a tech can't score it on a medicare patient. The really bad thing is some hospitals and practices grade everyone based on medicare guidelines at a flat 4% regardless of what insurance they actually have. This means that some full OSA suffers are being under-clocked in their AHI severity or even passed over all together much less someone with UARS who would get virtually none of their events scored.

As a sad note concerning the medical college experience when I was in class in 2015 for PSG the statics according to the books were that the average med student received a grand total of 2 and a half hours in their entire medical program on sleep medicine. I am curious if that was the case for you and I hope this changes in the future.

Ariseal wrote: ↑

Fri Jul 20, 2018 9:20 pm

I am also always happy to hear the viewpoints of cpap users who are not medical professionals and of their experiences with sleep apnea and the various PAP devices and mask. Anything I can learn that will help my future patients have more peace of mind would be great to have.

That's a very refreshing attitude for a sleep tech to have, usually they come swaggering in here all ready to tell us what's what, and how things really should be (and they're usually wrong).. Someone in the biz coming in to learn more of the patient perspective so as to be able to be better at their job, it's very refreshing.

I have talked to multiple different techs that have been in the field for 20+ years and they all have different ways of doing things. I value experience but it does not always mean they are correct either. Hell I have personally heard Dr.s say the AASM are a bunch of idiots. Different approaches work for different people and there is never any one hard fast rule that applies to all.

Also thank you for your reply Palerider.

Edit: I would like to add that I freely admit many users of this forum probably know more about about the workings of the cpap machines than I do through their own independent research. As a tech I have worked with a grand total of 2 cpap machines and most have been a Resmed model. Then most techs access the setting from the program links on their screens and not directly at the machine itself. Techs are generally only concerned with pressure and leak while titrating the patient. Some techs work for DMEs and they probably know a lot more, but then they are likely biased from their DME job and not open minded at the different options.

Ariseal wrote: ↑

Fri Jul 20, 2018 10:58 pm

Some techs work for DMEs and they probably know a lot more,

Don't bet on it. We hear all sort of.... well, I'll be kind and call them "misstatements" because "lies" sounds so harsh.

Well I love a good discussion and debate so if you ever have issue with any of my posted information. Please feel free to let me know and ill check my reference points. I think of myself as more knowledgeable about the hookup side of things and medical issues involving OSA than the machines themselves but I certainly don't know everything and I don't mind being proven wrong.

Hello and welcome. I have had so many sleep studies I've lost count, maybe 8 nights in various labs and at least two days. For the most part any issues were not the fault of the tech, but more facility or procedure related. If I were to give tips to the tech, it would be along the lines already discussed regarding listening to the patient. One tech didn't want to get me another blanket in the frigid A/C. She gave me some blah blah about sleep temperatures and was leaving the room, dismissing my request. Back then I wasn't as assertive as I am in my old age, but I summoned the nerve to tell her, I've been sleeping with me every night for nearly 60 years. I think I know more about what I need to be able to sleep than someone who just met me.

Another time I was having mask trouble and a different tech came in to check on me rather than the one who set me up. She was real irritated with the other tech who had put a mask on me that was notorius for being problematic. Don't know why she chose that mask. If she had just asked me she could have found out that I was exclusively a side sleeper with my hand under the side of my face, so a mask with tubing along both sides of the face was a long shot for me.

You mentioned not being a big fan of pillows masks for sleep studies. I can understand that getting in the middle of the study and finding out they need a full facemask would be frustrating. Another thing to consider regarding nasal pillows masks - you will never get a good fit with pillows in a fixed slanted position on a person with slotted nares. I can only use masks where the pillows can be rotated to a straight up and down position.

My only other insight is one you may go a lifetime as a tech but never need, but I'll throw it out there just in case. It happened in two of my studies - different labs. When you have a patient with limb movements, please give the situation a bit of extra attention. Twice my reports came back with very few limb movements noted. Since the reports include only what happens during sleep time, they missed information very important to my case. Found out later I was experiencing augmentation on a dopamine agonist. It was causing my movements to happen outside of when I was asleep. When I got the report I knew it was not reflective of my entire experience. During a time I felt I was dozing in and out, the movements were rapid fire for nearly an hour. When they reviewed the data at my request, there were over 300 periodic limb movements in what was classified as wake time. A sure indicator of augmentation. But even the doctor I had then didn't recognize it and kept increasing the med and calling it the progression of the disorder. When it happened again after I switched docs, when the report was reviewed upon request, she immediately started weaning me off the med. Not sure how much techs are allowed to comment on sleep studies, but it could be helpful go a bit outside what is required when an anomaly is seen.

Good luck with your career. You sound like a tech I would have been glad to have.

kteague thank you for your reply.

Hmm to address your points lets start with your temperature experience. So sometimes still and more so in the past temperature in sleep rooms was kept pretty low. This actually had nothing to do with what helped patients sleep and much more to do with something called sweat artifact. If a patient sweats excessively it will cause an interference in the EEG electrodes on the head that will cause the wave forms on the screen as a whole to take a waving motion. The greater the sweat artifact the more the waves distort and the study becomes hard to read. However that said I have found that patient have very different temperatures at which they sweat and some people sweat far more than others. The lab can be a comfortable 70 degrees and not need to be an icebox and most studies will come out fine. As for the temperature control for the rooms that can vary depending on the location. In some locations like a hospital the tech may have individual temperature control over the rooms or at least access to someone who can change it. At some labs like my current one in a Dr.s office there is only one central thermostat and if you have multiple patients with different temperature preferences finding a happy medium can be challenging. Also some labs will not let the tech touch the temperature at all (which is dumb IMO). Still there is no excuse for rudeness and the tech if faced with one of those issues should have communicated that to you better. If a patient is uncomfortable then they are not going to sleep and then the study is for naught, so I would defiantly rather deal with some sweat artifact than a non sleeping patient.

I appreciate the info on the slotted nares next time I need to use a pillow mask on a patient.

Concerning the limb movements. What a technologist is allowed to document is based entirely on the reading DR. Some Dr.s encourage strict documentation from techs but only along the lines of certain things and some leave it entirely up to the technologist to decide.Technologist are trained to score PLMS while in sleep and most of the sleep software programs will only allow you to score them in a sleep epoch anyway but a side note can be made for excessive wake leg kicks if they are rhythmic in nature. Unfortunately even if the technologist in question had documented your leg movements if the Dr. themselves did not catch them then they may have ignored the note anyway. Regardless I am glad that your proper issue was finally diagnosed and addressed and if I run into excessive rhythmic waking leg kicks in the future I will make sure to note them somewhere in my report.

Thank you for the encouragement although I do not plan to stay in sleep forever and I will hopefully be going back to school soon for Microbiology, although still working as a tech throughout college.

As to the temperature, I was only asking to not have to shudder all night. Thanks for the information about sweat artifact. Makes sense.

Good luck with your career plans. Hopefully your time in the sleep field will be a good transitional job.

I believe that knowledge is never wasted and I am sure neuroanatomy and sleep medicine will not be useless in research virology. You never know when old skill sets can be used to address a newer problem.

No one should have to shudder all night. That is just no fun and I know I certainly couldn't sleep at those temperatures.

I am curious on one point (and others please weigh in too) since you have had so many studies. Have the receptionist ever told you properly what to bring or expect the night of the study.

I was very fortunate to have an awesome tech and awesome sleep study. I was expecting the worst, and the great tech got me started really well.

First, like you, she chatted with me as she got me set up. Told me about the test and equipment, and helped me feel comfortable. One thing that I really appreciated is that she she set me up well for a possible split night study. She fitted me with the mask and then had me sit with the cpap running for about 10 minutes before the sleep study started. This was to give me a feel for it so that it would not be a total shock in the middle of the night. She also chose the perfect mask for me and fitted it perfectly. (later, when she started the titration, she put on the mask, and I slept over 5 hours straight. I was amazed).

About an hour in, I woke up and needed to use the bathroom. I did not know that this was common with sleep apnea. I just knew I was hooked up, and I was embarrassed and didn't want to ask to go to the bathroom. This must happen a lot. She came in, commented that she realized I was awake and needed to check on a wire connection. This broke the ice and got me up for the bathroom. Well done. Later, when she woke me for the change to titration, she suggested a bathroom break. Very smart.

A couple other things. When my mom had a sleep study years earlier, they woke her at 5am to stop the study and send her home. I am a severe night owl. One reason I avoid a sleep study was that I knew I couldn't sleep at 9am, and didn't want to be pushed out at 5am. I think this sleep lab said I could stay up until midnight if I wanted. And they woke me up around 8am. Much better.

Zoocrewphoto I am very glad that you had a great tech and a pleasant experience with your study. I like to prep patients for cpap ahead of time when I can as it does make the transition easier including possible splits. This is called an acclimation process. Unfortunately at my new job I usually have three patients a night and I just don't have that amount of extra time to acclimate each potential split patient and proper fit them. I really wish I did.

First I always suggest to my patients to use the restroom right after hookup but before I get them in bed. I also tell my patients to not please not hesitate to call on me if they need anything during the night especially the rest room. I also tell them that if for some unforeseen reason the speaker is not functioning properly or turned down to carefully sit up in bed, mindful of the wires and wave with their hands and that I will notice and be right in there. I tell patients that is what I am there for and not to be embarrassed about asking for a restroom break it happens all the time.

When I was at the hospital previously the first year they had their sleep center in a hotel the hospital owned and we could let the patients stay in bed for quite awhile after we unhooked them even after the techs left for the day. However most locations that is not the case. your average technologist shift goes from 7am to 7pm. They are strictly not allowed overtime unless approved by the Dr. and in many labs there is not anyone else coming in right after and the patient cannot be left alone as that is a liability. In cases like the office I am not now I have to lock up and turn on the alarm when I go as well. So the absolute latest I can wake a patient up is 6am and still get all my work done and everything cleaned and put away. so when it comes to wake up times it is usually location dependent unfortunately. Being a night owl myself (go figure ) sometimes you can request a daytime sleep study from some places if they are offered. Just make sure it is a daytime PSG and not an MSLT or MWT which also take place in the daytime.

I had no problems with my two night sleep study and titration and the pressure settings were very close to the mark. It was the follow up that was not good (or should I say non-existent). The company, SNORE Australia, said in their materials that there would be follow ups at certain time intervals to see how I was progressing. They didn't happen. They'd got their money from Medicare and that was it. If it wasn't for this and another forum I would probably not be using xPAP for my OSA and I'm so thankful that I found them.

On top of that I went to a DME for a loaner machine so that I could work a few things out before finally forking out my hard earned cash for a machine of my own. The DME had their own technician of sorts who, when she found out that I had been adjusting my own settings, went ballistic. What she didn't expect is that I responded in kind including asking her not to lie to me. ("You are not legally allowed to change your own settings!") My response was immediate - "Prove it!" She couldn't and was really put out when I could. She reminded me of Pugsy's second tech. I am normally mild mannered and accepting but this time took great delight in putting this idiot in her place.

I've been using PAP for over two years now and what has become very evident is that the study of sleep disorders, especially OSA, is in it's infancy. As we don't get the insurance breaks here in Australia as you do in the US it's not seen as profitable and therefore pushed into a back corner. My GP, a great doctor, admitted to me without any prompting that I knew more about PAP therapy treatment than he did.

So to hear a sleep tech wanting to know how they can help their patients is very refreshing. There are some incredibly knowledgeable people on this forum so you are correct in that you can continue learning while perusing the threads.

Thank you for your reply Holden4th.

That really sucks on the follow up and I wish I could say that wasn't a problem in the states but sadly it is here as well. PAP patients are often discharged to a DME or left on their own especially if their study was performed in a hospital and their general practitioner is not a sleep Dr. The actual recommendation is for a cpap patient to have a new full study performed every five years, however many times I have seen patients on ancient machines far out of that date range. You are correct that it is not illegal to change your own pressure setting. It is just highly discouraged because over titration can cause problems of it's own so doctors prefer patients not to be able to affect the pressure setting. Of course we all know there are ways to jailbreak any device.

Now while they are still learning new things every year about sleep disorders the technology is actually very old. The EEG technology that is used to monitor the brain waves is over a 100 years old in fact. However for a long time the technology rarely underwent any major changes until the conversion from analog systems to digital years ago. Far before my time but sleep studies used to be reams of paper instead of data files. The cpap manufacturing companies are constantly trying to come out with smaller sleeker machines and more comfortable mask every year but the tech behind the studies needs some major overhaul for all neuro fields like the development of wireless electrodes for one. However you are most definitely correct that sleep medicine has been woefully neglected for many years and is only just now starting to receive more of the attention it rightfully deserves. To top it off sleep is a bastard child fought over by several medical fields, mainly respiratory and neurological. In some areas it's covered by Respiratory and in some by Neurological and in yet other by Cardiac due to the impact on the heart long term. The AASM which is the American Academy of Sleep Medicine and writes most of the rules we follow for sleep here is an old organization that is slow to change and adapt newer policies.

However one feather in the hat for Australia is that when I was in school a college in Sydney was the only place in the world that offers a sleep PA masters program. That may have changed since then, as I do not know personally.

The really sad thing I can't ever fathom is why sleep studies are not straight up preventative care that everyone just undergoes at some point in there life. The money the stupid insurance companies could save in heart medication alone years down the road would be staggering. Untreated apnea is horrible for the heart and their is a reason that a large number of people with OSA over 30 have high blood pressure.