"Impact of COVID-19 on Sleep Centers and Mitigation Strategies" Indira Gurubhagavatula (9.9.2020)

September 10, 2020

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00:00Points, and this is another
00:02picture that shows recent trends
00:03in in in this northeastern region
00:06compared against California,
00:07and we can see that Massachusetts,
00:09New York, Connecticut, the cases
00:10are still continuing to rise slowly.
00:12New Jersey has more cases in the slope,
00:15maybe a little bit,
00:17but steeper than the other States
00:19and California is really taking
00:20off with lots of activity.
00:22So just remember,
00:23when you look at these graphs,
00:25there also reflection of how much testing
00:28is being done and how available is it in?
00:31Are people going to get tested?
00:33Anne Anne Anne reporting can
00:35really impact these numbers,
00:36but they are a place to start.
00:40So having said that,
00:41when we issued our guidance it is
00:44not a fixed firm thing that that
00:47applies at any point at anytime,
00:49geographically or over the course
00:51of the pandemic as things evolve,
00:54this really is a living document,
00:56and so anytime we're looking
00:58at sleep operations,
01:00we need to make sure we are
01:02adjusting our approach according
01:04to what's happening locally.
01:06What sorts of rules and guidance
01:08or being issued?
01:10At the federal level,
01:11the state level at local level
01:13are are hospital employers and
01:14then what is the data saying is is
01:17the signs the science can evolve.
01:18It can change.
01:19We thought it was mainly contact
01:21spread and then we discovered
01:23it's actually aerosol based.
01:24So you know things keep changing.
01:26So the guidance this anything
01:28about to share with you today is
01:30not meant to be prescriptive.
01:32Especially given that we have a
01:33positive data in many of these
01:35recommendations,
01:36so it's really considerations and
01:37things that we should be thinking about.
01:41So we as of July it this is no longer
01:44inside the Public Safety Committee,
01:46but we're actually convened a task force,
01:49and the six people on the left, or members.
01:52We have a policy ography technician
01:54and respiratory therapist.
01:55We have doctor burning King whose
01:57occupational medicine expert,
01:58we have sleep specialists in Wisconsin,
02:00Florida, North Dakota and Chicago, IL.
02:02We have an infectious disease
02:04consultant and we have a vice chair
02:06from Palo Alto Doctor Sullivan.
02:08We also work with Doctor Rimar,
02:10who's the current president.
02:11The ASM and service,
02:13our liaison with the board of directors.
02:16Doctor Epstein and Mr Heffron.
02:17Our staff members and I'm serving his chair.
02:23So we put all of our heads together
02:25an in our latest revisions,
02:27an update to the online guidance.
02:29We grouped all our recommendations
02:31into three categories and
02:32they're there for your review,
02:34and I encourage everyone to to
02:36take a look and see what you,
02:38whatever you need it is.
02:39We tried our best to make
02:42sure that it's there for you.
02:45All the FAQ we continue to
02:47receive submissions on line and
02:49we have up to 15 of them now.
02:51We've kind of lump them all
02:53together in different categories.
02:54For sleep clinicians.
02:55We also took all the recommendations
02:58that the CDC has issued along
02:59the way and went through the all
03:01the volumes of information and
03:03cleaned out the portions that
03:05are relevant for sleep practices,
03:06and we summarize them in a convenient way.
03:10And then we have 1/3 tab that
03:13includes specific considerations
03:14for Sleep Medicine that are not
03:16discussed by the CDC and that we've
03:19come up with based on consensus and
03:21using the best available evidence.
03:24So as far as the FA cues, as I mentioned,
03:27there are 15 different ones,
03:29but I'm not going to go through all of
03:31them now, but they cover things like.
03:33How do you decide if your lab should
03:35close and when it should reopen?
03:37What sorts of information should
03:39you be consulting?
03:40What number should you be looking at?
03:42And then how do you?
03:43What types of strategies and control
03:45should be thinking about to mitigate
03:46viral transmission risk among your
03:48personnel inside your facility?
03:49What sort of environmental controls
03:51should be should be thinking about an?
03:53What kind of strategies to use an
03:55outpatient practices in the lab?
03:57What should you tell a patient if they say,
03:59hey, I I'm not?
04:00I'm worried that the see Pap Machine is
04:02gonna blow the virus further into my lungs.
04:04What sorts of advice should be giving our
04:07patients about C Pap if they get sick?
04:09And what're payer policy saying?
04:11So all of that is in there.
04:14the CDC recommendations that are relevant
04:17for us were categorized into three groups.
04:20The first includes patient care strategies.
04:23the CDC issued this guidance in
04:26mid July and there they said they
04:29were concerned that patients who
04:32really needed health care services
04:34were not showing up,
04:36and so they issued guidance
04:39on how to reopen facilities.
04:42So patient care strategies.
04:43the CDC was really recommending Tele
04:46Medicine and how to go about doing that.
04:48They were also looking at how
04:50do you prescreen patients before
04:52they arrive at your facility?
04:53When should you use COVID-19 testing?
04:55They also provided strategies
04:57for healthcare providers in the
04:58in the workplace setting.
05:00How do you protect yourself so they have
05:03guidance on what types of PP should you use?
05:06When is it appropriate?
05:08Use which type of PPE?
05:10And then finally cleaning instructions
05:14for health equipment and facilities.
05:19And then finally the third category,
05:21or all the unique and special
05:23considerations that need to be taken
05:25into account in sleep centers.
05:27So outpatient practices in laboratories.
05:29And there we used our consensus
05:31to come up with recommendations,
05:33and that's where we'll be spending
05:35the rest of today talking about.
05:38So those recommendations that apply
05:40specifically to Sleep Medicine,
05:41we categorize them into five areas.
05:43The first is your general approach
05:46to care delivery and what kind
05:48of model are you going to use.
05:50We can't continue to do face to
05:53face visits and lots of in lab
05:55tests in this environment,
05:57and so how do we go about
05:59delivering care using other models?
06:01The second has to do with pre testing
06:04patients before they show up for COVID-19.
06:07The third has to do with diagnostic and.
06:10Titration studies and in home testing
06:12the 4th category has to do with therapy
06:15consideration specifically related to C Pap.
06:18And then finally,
06:18how do you mitigate risk in your
06:21own practice?
06:22So let's look at care delivery.
06:24So first and foremost,
06:25any plan that you come up with
06:27or that you're thinking about
06:29has to conform with local rules,
06:31regulations and emergency orders,
06:32and so there are a number of areas to look.
06:35One is within your own institution
06:37or hospital,
06:38the other is the local guidance
06:40or regulations and then state
06:42and regional and national,
06:43and these can change and they
06:45can change very quickly.
06:46And it's a lot of information to go through.
06:50So it's important that your practice
06:51stays up to date on this information,
06:54so we had advised that you consider
06:57actually appointing someone whose
06:58responsibility it is to stay on
07:00top of all of this information and
07:02translate it for the rest of your team.
07:05And everything else flows from this.
07:07All the other decisions you
07:10make fluid flow from this.
07:12So next,
07:13uh,
07:13once you decide on other
07:15care delivery models,
07:17think about when it's appropriate
07:19to use other modes.
07:21So if cases arising and your locality is
07:24concerned about a new outbreak happening,
07:27and that the hospital is starting to fill up,
07:31it's a really good time to move
07:34to Tele Medicine approaches
07:35and not at the last minute,
07:38but preemptively start calling
07:40patients and converting them over.
07:42But are there newer return visits?
07:45Start moving them over and this
07:47is a function of is it possible at
07:50all there are there are accredited
07:52facilities that simply cannot take
07:55this on because they don't have
07:57the resources and as a result at
08:00the ASM actually offered free use
08:03of their telemedicine platform.
08:05During the pandemic, but but is it available?
08:07Is it feasable how much work does
08:09it take to onboard patients?
08:11And as your staff having to spend
08:13hours getting them to download a
08:14specific software and making sure they
08:16have a login ID and that it works,
08:18and they know how to do it,
08:20or all your clinicians uniformly
08:22trained and they're comfortable in
08:24getting enough on and off and
08:25in and out of these visits?
08:27And will patients actually
08:28accept it and agree to use it?
08:30So a lot of things to be looked at
08:32and considered as you rollout Tele
08:34Medicine and then another group that.
08:36Provides patient care or the DMV providers.
08:38The restaurant therapist who do the
08:41mass fittings and we have a C Pap
08:44clinic on site where patients could
08:46just walk in which has since been
08:48closed and so offering mass fittings
08:50remotely is another area that's evolving.
08:52There are some software that's coming
08:54out that can help with 3D image Ng,
08:57so moving forward that could change and
08:59we could have other resources available.
09:02And then use remote monitoring when you can.
09:05So instead of having patients show
09:07up with a C Pap machine that needs
09:09to be downloaded or an SD card,
09:12consider outfitting all of these
09:13devices with modem so that you can
09:16have remote access to their data.
09:18And there are some reimbursement
09:19codes that are available.
09:21They are on the SM website so that
09:23some of that activity is billable.
09:25And then consider using home based testing.
09:28So when are in our area when when
09:30there was a big spike in cases, a Cup.
09:33Two months ago,
09:34we actually closed our lab and resorted
09:37entirely to home based testing,
09:38and at the VA for awhile.
09:40They weren't doing either.
09:44And then next as you come up with
09:47these care delivery models be
09:49very clear and very specific with
09:51the algorithms that you develop,
09:54so there's no confusion around what
09:57to do or how to do it can see.
10:00You're allowing patients
10:01to assess themselves.
10:02They know when to seek care,
10:04so having advice lines or using the
10:07electronic patient portals offering on
10:09line assessment tools so that patients
10:11know when they need to come in,
10:13get evaluated, get tested,
10:16and so forth.
10:17Number of such questions can
10:19increase some practices.
10:20Referral practices decrease their
10:22business or close their doors,
10:24so some of those patients were were no
10:26longer able to access the lab directly.
10:29So giving patients access to this Direct
10:32Line of self evaluation can be very helpful.
10:36And in the process of closing down
10:38certain services or postponing them,
10:40think about how are you going to make
10:43sure those patients don't end up lost.
10:45And then when you do reopen
10:47and re offer those services,
10:49how are you going to prioritize
10:51and triage patients?
10:52So have something in place so that
10:54you continue to maintain access
10:56to care for patients have been
10:59postponed and that there is a
11:00way to get them back in quickly.
11:02The more emergent ones and then this is
11:05special group safety sensitive workers.
11:07So truck drivers and so forth.
11:09And they're offering important
11:10services during the pandemic,
11:11many of them when they show up to you,
11:14they have time sensitive licensure.
11:16They need to be evaluated
11:18and treated very quickly.
11:19So if there's a big run on home testing
11:21devices because your lab is closed
11:23and they now have to wait longer,
11:25you gotta think about can you come up
11:26with the priority system so they can.
11:28They can sort of jump the line
11:31and get tested earlier.
11:32And then think about how are you
11:34going to handle people who are
11:37showing up with your patient.
11:38The CDC recommends that visitor
11:40policies be put in place so that
11:43unnecessary visitors or restricted
11:44from entry in many hospitals
11:46have these in place as well,
11:48but some patients need family members
11:50to help them with because they're
11:52medically necessary to be there.
11:54Sometimes their actual medical
11:55personnel or attendance,
11:56sometimes translation services are needed.
11:58So how are you going to screen those people?
12:01What advice are you going to
12:03tell them you know?
12:05Are we going to have masks available?
12:07Do they need to be pre tested for COVID-19?
12:10All of that needs to be thought
12:12about and for us in our practice
12:14as far as translation services,
12:16we are using electronic.
12:18We have a number that we call so that
12:21we have somebody readily accessible.
12:23And then think about what to
12:25do for those who show up,
12:26and they say I'm not wearing that mask or
12:28and they don't maintain social distancing.
12:30Have a policy in place so that your
12:33staff are not caught off guard.
12:35And then there may be a time when a covid
12:39cases actually linked to your lab,
12:42or someone who visited your
12:44lab or works at your lab.
12:46So make an active effort to
12:49participate in local contact tracing,
12:51and all of this, all of these policy's
12:53need to flow from emergency orders,
12:56regulations policy's guidance
12:57issued by your institution,
12:59and by local, state,
13:01and national authorities.
13:04Now as far as Covid Pretesting.
13:09Pretesting the decision to use pre
13:11testing or not is can be run by just
13:15isn't even available in your area and
13:17how long does it take to turn around
13:20and what are the rules around it?
13:22And are there rules were certain
13:24patients have to get tested?
13:26So for example somebody who just
13:28came out of a high risk area or had
13:31a recent exposure now plans to work
13:34in Healthcare so the turn around time
13:36in some places has gotten very long
13:38when we first started in our facility.
13:41Doing covert pretesting,
13:42we were able to get results back relatively
13:45quickly within one to three days,
13:47but now it's taking longer and so
13:49if if it's taking 10 days seven days
13:51it might almost not be worth it
13:54because there's risk of re exposure
13:56if they were tested 10 days ago.
13:58And then you're planning to
14:00do your titration tonight,
14:01it's not clear what their
14:03covid statuses anymore,
14:04so you need to think about.
14:07Whether that's the right way
14:09to go and then the context,
14:11so a negative test would be having a
14:14negative test on hand would be helpful
14:16if you're doing a more risky procedure,
14:19like a titration,
14:21which can be potentially aerosol
14:23generating versus a diagnostic
14:24test where the need for testing
14:26may not be as significant based
14:29on what's happening locally.
14:30And it's also important to
14:32interpret these results in the
14:33context of pretest probability,
14:35which is a function of local prevalence.
14:37So if you have a highly prevalent condition,
14:39if covid is is,
14:40if there is a major spike in activity
14:43and you have a negative test result,
14:45then you gotta look at that
14:47with a little bit of.
14:49You gotta question that result,
14:50and is it a false negative?
14:52And similarly test methodology with
14:54the nasopharyngeal swabs at this?
14:55Not swab isn't put in all
14:57the way or done correctly.
14:59You can get a false negative test.
15:01So if it doesn't fit the picture,
15:03the person might need to be retested.
15:05So if they have symptoms, for example.
15:08Or there is a very high prevalence area,
15:10or there's a high suspicion
15:12that they have a negative test.
15:13May not be as meaningful and similarly
15:15in a very low prevalence area of
15:18false positive test as possible.
15:19So, and it's important to have a policy
15:21in place where you think about, well,
15:23how are we going to handle a positive result?
15:26What's the next thing that needs to happen?
15:28Who do we refer to?
15:30Who we call?
15:31How do we get that patient managed?
15:33So in terms of covid status,
15:34if someone has been tested
15:36their different categories,
15:37they can fall into,
15:37they may be someone who is currently
15:39under quarantine or presumed positive,
15:41or their status is unknown.
15:43Or they may be presumed to be
15:44negative or completely recovered.
15:46And really we should not be
15:47bringing people into our lab who.
15:49Or anything other than presume
15:51negative or recovered.
15:54And then as far as sleep
15:57testing considerations.
15:58If we, when we when are disease
16:01activity was at its peak in April,
16:04may we actually closed our lab
16:06and we went to home testing.
16:08And so if you implement that
16:10type of home testing protocol,
16:12then in the in the execution of that
16:14protocol it's important to continue
16:16to maintain the principles of social
16:19distancing and contact precautions.
16:21So we adopted initially a male model
16:24where we would Mail the device and
16:27they would Mail it back to us.
16:29One of the concerns with that
16:31is that the Mail service has
16:33gotten very slow and the demand
16:35for these devices has increased,
16:36so it becomes a bottleneck and it
16:39ends up limiting access to care.
16:40So we then switched to curbside the
16:43curbside exchange model and think about,
16:45you know if you're going to do that,
16:47make sure that you have
16:49scheduled appointments.
16:49You don't have a big buildup of people
16:52all in a big crowd waiting to turn it in,
16:55so it really is they drive by.
16:57They handed up a hand it to the.
17:00To the hospital personnel
17:02and then they leave,
17:03and likewise the dispensation
17:05and the retrieval occur.
17:06That way outdoors,
17:07and then the instruction that we were
17:10doing initially was face to face.
17:12But we've had to be adaptive,
17:14and so think about doing this
17:16to maintain social distancing,
17:18where using either printed both
17:20shores or get away from that.
17:22So you're not worried about context
17:24transmission and use electronic
17:25ways of instructing either video
17:27that can be viewed asynchronously,
17:29or Tele medicine visits where you're
17:31actually. Providing life support.
17:35And then, uh,
17:36after Retrieval and handling the package
17:38follow contact based precautions.
17:39Consider using single use.
17:41Store fully disposable devices.
17:42Some labs are doing that,
17:44others are finding it cost prohibitive.
17:46Others are using component parts that
17:49are disposable and others that are reusable.
17:51And if you are using a reasonable device,
17:54make sure you're thinking about
17:56what are the CD CDC recommendations
17:58on cleaning and disinfection?
18:00What is the manufacturer saying and
18:02do you have facility policy's and
18:04the technologists are handling this?
18:06Spices should be using appropriate
18:08PP for that activity,
18:09and some labs are actually waiting
18:1172 hours and taking the device
18:13out of service for that period
18:15of time before they dispense it
18:16again to the next patient.
18:18So where did that come from?
18:20So that was from this study that
18:22was published in The Lancet.
18:24In April an what this group did was
18:27they took a 5 microlitre aliquots
18:30of solution that had virus in it
18:33and they put it on a variety of
18:36services services and then they went
18:38back and they checked to see could
18:41live virus be retrieved using viral
18:43transport media from the surface is
18:46and they found that in on plastic
18:48that the virus live virus could be
18:51retrieved in three after three days.
18:54So this doesn't mean that you
18:56can that that that
18:57translates into active infection.
19:00In fact, we don't know of cases where
19:02the the only source of transmission
19:04was through handling mailed packages,
19:07but one of the principles we appear
19:09to was airing on the side of caution
19:12and in the interest of Public Health,
19:15some labs are following that and keeping
19:18these devices out of service for three days.
19:22Now, what about laboratory
19:23based testing here?
19:24Our group felt that it was important
19:27to weigh patient preferences against
19:28clinical judgment to determine
19:30whether the study should be done in
19:33the lab or should be done at home.
19:34So you may have a patient that says, yeah,
19:37I could do it at home, but I really cannot.
19:41You know there are eight people
19:43who sleep here.
19:44It's too noisy. It's too cold.
19:46I'm too stressed.
19:47I'm not safe, so they may strongly
19:49prefer to come into the lab.
19:51And if the.
19:52Pair reimbursements,
19:53or is willing to cover that,
19:55then then that's an option,
19:57but on the other hand,
19:59if it's somebody who.
20:00As risk factors for severe COVID-19 you have
20:03questions about you know what would happen,
20:06whether they might be infected,
20:07or if they were to get infected,
20:10then the result could be catastrophic.
20:12So somebody who recently had cancer,
20:14chemotherapy, or you know,
20:16is the sole breadwinner for their family,
20:18and they are in a high risk
20:20group for severe COVID-19.
20:22So someone like that,
20:23you may want to try to get by with
20:26with home based testing strategies,
20:29and if they are appropriate
20:31based on the clinical setting.
20:34To help you with the C,
20:36ASM does have practice guidelines
20:39available for both diagnostic
20:41testing and also for the delivery
20:44of positive airway pressure.
20:46The other thing you can consider
20:48is actually using Empirix C Pap.
20:50So instead of Poly Sonography
20:51you can try auto titrating,
20:53see pap or just empiric C Pap
20:55without any kind of testing.
20:57So how do you decide who should get
20:59that type of therapy where you're
21:02just kind of looking at them and
21:04saying yeah I think you can try C Pap.
21:07So rather than just kind of rule
21:09of thumb in it there are screening
21:11and assessment tools.
21:12We had a task force that looked at this.
21:16And published all the tools that
21:19are available and that is available
21:21in the JCSM in the July 2018 issue.
21:24The The The.
21:25The thing about these tools is that
21:27there is no specific threshold.
21:29So if you have a score on a stop bang
21:32of X or your Berlin questionnaire
21:34result is why then that person
21:37can go straight to Empiric C Pap.
21:39We don't have that kind of criteria
21:42that validated so so some of this is
21:44going to have to be based on clinical
21:47judgment and the best guess and the
21:49best clinical expertise of the evaluator.
21:51There is a tool that we
21:53developed at our institution.
21:55The multivariable apnea prediction score.
21:57And that's also included in
21:59this in this assessment review
22:01document and there the score goes
22:03from zero to one and at the VA that
22:06you know pre testing with PSG,
22:08RHS 80 is not required
22:10before C Pap dispensation.
22:11So this is something we've been able
22:14to do and have done for a few years now.
22:18And we used a threshold score
22:21of .7 and found that.
22:23The adherence with C Pap after
22:25that appeared to be similar to
22:27those who didn't get testing.
22:29Now that was a different model care
22:31delivery model where the patient was
22:34assessed and then within one to three days,
22:36sometimes the same day.
22:38They had a live in person,
22:40extensive education and face to face.
22:42C Pap set up.
22:43So this environment under COVID-19
22:45is quite different from that
22:47where there drop shipping C pap
22:49machines to patients homes and
22:51live in face to face education.
22:53There hasn't been as readily available,
22:55so how well it would work is is unknown,
22:58but Medicare has now will cover C
23:00Pap based on clinical assessment
23:01without diagnostic testing,
23:03and they have not clarified whether
23:05at some point down the road
23:07the patient should get tested.
23:08Once this emergency is over.
23:11Now let's think about C Pap itself.
23:14So in order to understand C Pap,
23:16we gotta look at the way that
23:19the virus transmits.
23:20So there are different types of transmission,
23:22and it appears when a person coughs,
23:25sneezes,
23:25or talks,
23:26or even exhales droplets escape
23:28from the nose mouth and the larger
23:30ones will drop immediately,
23:31inform the person and not travel as far,
23:34but the smaller ones are the ones
23:37that can stay airborne and where the
23:39virus stays ERISA Lizet they can travel.
23:42A lot longer,
23:43not farther distance in stays suspended
23:45in the air for a longer period of
23:47time where they can be inhaled,
23:49so Ebola is contained in these
23:51larger droplets that fall,
23:53and so contact based transmission
23:54is a is a more significant method
23:56of transmission.
23:57But measles chicken pox,
23:58they can stay suspended in aerosol
24:00form and travel much farther,
24:02so the coronavirus is probably
24:04somewhere in the middle,
24:05which is where the six feet
24:08distancing rule comes from.
24:10So the initial suggestion that
24:12this isn't just contact for,
24:13but maybe you're born came out of
24:15the restaurant in the Guangzhou
24:17Province in China,
24:18where an infected person he didn't
24:20know they were infected at the
24:22time that they had this meal with
24:24a bunch of family members and later
24:26that day they went and got tested
24:29and were confirmed to be positive
24:31and eventually over the course of
24:33the next few days a number of people
24:35who sat at the same table and we're
24:38from the same family got infected.
24:40But also people unknown to this family,
24:42two other families that were
24:44happening to be sitting in adjacent
24:46tables also had infected members.
24:48So total of nine people got infected here,
24:50whereas 8 staff members and 70
24:52three other people who were in the
24:55restaurant at the same time tested negative.
24:58And so it was traced back to this air
25:00conditioning unit and that the air was
25:02blowing one way out and then reverse flow
25:05was happening in the other direction.
25:07And so everybody who sat in front of this
25:09air conditioner ended up getting sick and
25:12then a second occurrence in the Skagit
25:14Valley Choir in Washington on March 10th.
25:16This group took all sorts of precautions
25:18they handed out sanitizer at the door.
25:21Nobody shared sheet music.
25:22There was no hugging or kissing
25:24or close contact.
25:25People stood away from each other and
25:27nobody was known to have been sick.
25:29Just like at the restaurant,
25:31nobody had symptoms,
25:32nobody was coughing or sneezing,
25:33and yet 75% of the people who
25:36attended got infected by one person.
25:39Who happened to be infected?
25:40So what this exposed was that
25:43transmission before people develop
25:44symptoms is possible and that in
25:46fact 80% of infections that are out
25:49there are thought to come from a
25:51minority of these super spreaders so
25:5320% or so people end up infecting
25:56lots of others by just being at
25:58the wrong place at the right time.
26:01So the Super spreaders in a
26:04super spreading event.
26:05And then as far as the emergence
26:08of airborne transmission inside
26:09healthcare workers with this
26:11particular virus that that started
26:13emerging early on when universal
26:15masking wasn't necessarily the norm.
26:17But Wu Hon started noticing a
26:19disproportionate number of cases
26:21and deaths among anesthesiologists,
26:23critical care specialist and ophthalmologist,
26:25an EMT specialist, and Iran,
26:27where at least 220 NT Surgeons
26:29were hospitalised.
26:30There were twenty more placed in isolation,
26:33and one resident actually had a cardiac
26:36arrest because of my carditis in Britain,
26:39reported 2 E NT doctors on Ventilators,
26:42and Stanford issued a white paper
26:44saying that your nose and throat in
26:47any other specialties that do high
26:49risk procedures like intubation,
26:51endoscopy, Bronx or layering,
26:53osca,
26:54P or at risk for increased risk
26:57for transmission because of high
26:59viral shedding from the from the
27:02nasopharynx in the oral fairings.
27:05So as of now,
27:06in addition to these procedures
27:08like Endoscopy and learning Osca P,
27:10the CDC also considers C Pap and Bipap
27:12to be aerosol generating procedures.
27:14So what that means is that the virus
27:17can stay in higher concentrations
27:19and can travel a much longer distance
27:22and it can stay in the air longer
27:24than just somebody who's infected,
27:26who's coughing, sneezing,
27:27talking or breathing.
27:28So there's a higher risk of exposure and
27:30infection for those who are hanging around.
27:33People who are on C Pap or Bipap.
27:36And data for this also came out of
27:38the first SARS epidemic in Toronto,
27:40where half of all of the cases that
27:43were transmitted in the hospital
27:45were in health care workers.
27:46Three of them died,
27:47and they seem to happen during
27:49the delivery of nebulae.
27:51Zehrs,
27:51high flow oxygen and definitely
27:53positive pressure ventilation.
27:54So then the next question is,
27:56is there a way that we can
27:58kind of mitigate
27:59that risk and or some masks
28:02actually less risky than others?
28:04The data on all of this is very,
28:06very low right now,
28:08including the use of other things like viral
28:10filters and other adaptive technologies,
28:12but this study done by huy in the
28:15European respiratory Journal looked
28:16at two types of nasal pillows,
28:19and they compared this against
28:20one type of full face mask,
28:22so it was very specific.
28:24Brands that they tested and
28:26they tried increasing levels of
28:28continuous positive airway pressure.
28:30And this these were not actual patients.
28:33This was a mechanical patient
28:34simulator and what they found was
28:37that with increasing C Pap pressure,
28:39the dispersion distance increased
28:40and if they simulated lung injury
28:42than the dispersion was even.
28:44Even worse went even farther,
28:46and similarly they saw a similar
28:48pattern with the use of high
28:50flow nasal cannula oxygen,
28:51whereas with the full face mask they
28:54did not see that type of dispersion.
28:56But it turns out they were
28:59measuring dispersion of smoke.
29:00In the sagittal plane directly in front
29:03of the patient and this full face mask
29:05that they evaluated had the exhalation ports,
29:08the isolation holes were in a circle evenly
29:11distributed around the elbow connector,
29:13so there couldn't be a stream
29:14for them to measure because the
29:16exhaled air was being dispersed in a
29:19circumference around the connector,
29:21so we don't know for sure that that
29:23mask is necessarily safe to use,
29:26because the data and the
29:28model that they used,
29:29and it's only one mass that they tested.
29:32So we can't say for certain that a
29:35specific mass type is better than others.
29:38Now the other question is then,
29:40in this scenario,
29:41should home C Pap be continued in someone
29:44that you suspect might have COVID-19?
29:46Or if you know that they have it?
29:49So in that case what we suggested is
29:51that you gotta really look at what is
29:54the risk to the patient of discontinuation.
29:57What is the risk to
29:59others of continuation so?
30:01We recommended that the any
30:02decision to either continue or stop.
30:04He based on a risk benefit assessment.
30:07So what that means is that you take
30:09a look and see what are the risks of
30:12stopping C Pap for just the short term
30:15until the person recovers from COVID-19,
30:17and for most people it shouldn't
30:19be a big deal.
30:21They should be able to get
30:23off without issues,
30:24but there is a subset of patients
30:26who may be at risk for acute
30:29cognitive decline or motor problems.
30:31Coordination, falling cardiovascular events,
30:32arrhythmias, and so forth.
30:34And some who may be at risk
30:36for driving accidents.
30:38Now they shouldn't be driving.
30:40They should really be quarantining.
30:43But the question if you decide to
30:45stop C Pap is then can we actually
30:48manage the risk that could result from
30:51that for this subgroup of patients.
30:53So one thing you can consider in
30:55giving such advice is than look
30:58at offering fall precautions,
30:59refer them back to their cardiologist.
31:01Make sure that their medical
31:03management management is optimized,
31:05advise them against do it using any kind
31:08doing anything risky where they could
31:10have an accident or hurt themselves,
31:12and then look at other
31:14forms of bridge therapies.
31:15So if they already have an oral appliance,
31:18go back and use that.
31:20Consider position therapy.
31:21Either pruning the patient or using a wedge,
31:24pillow, or sleeping upright in a chair,
31:27staying away from alcohol,
31:29sedating medications,
31:29keeping any nasal congestion under control.
31:33So the risk of choosing to continue this
31:35C pap in somebody who may be actively
31:38infected is really the risk potentially
31:40of transmitting the infection to others.
31:43Knowing that with the increased
31:44pressure there could be the issue of
31:47the virus could hit surface is that
31:49you didn't even think of cleaning like
31:51the ceiling or much farther away.
31:55And can the risk then to others
31:57is that manageable?
31:59So can the patient completely
32:01quarantine self isolate,
32:02have their own bathroom and protect
32:04their other household Contacts?
32:06Or do they live in a very congested,
32:09crowded environment where
32:11it's impossible to isolate?
32:13Where they are they in a multi unit
32:16dwelling which shared ventilation
32:17systems where it's easy for viral
32:20dispersion outside their home?
32:22Even so,
32:22these are all things that should
32:24be under consideration and then
32:26in the inpatient setting there's
32:28more information that's available.
32:30So patients should have some
32:32kovid testing results perhaps,
32:33and so looking at what is the
32:36hospital saying for patients
32:37who have pending covid tests?
32:39And what is that? What is their policy?
32:42What is the local health department's policy?
32:45At the very least,
32:47you should be looking at CDC recommendations.
32:49On protecting one mitigating risk during
32:52a GPS aerosol generating procedures in
32:54someone who's COVID-19 test is pending.
32:57If you suspect that they have it or
33:00that they definitely tested positive,
33:02then the we should attempt to avoid
33:05positive pressure therapy as much as
33:08possible in specific environments where
33:10there's an absence of ventilation,
33:12you don't have a negative pressure room.
33:15The staff don't have adequate access
33:17to PPE or other mitigation strategies.
33:20An if the test is negative,
33:23make sure you interpret that in
33:25the appropriate clinical context.
33:26So think about the possibility
33:28of a false negative test.
33:30If your pretest probability is very high.
33:32So if the patient appears to be sick,
33:35or you suspect that they have it.
33:38If the region has a very high
33:40penetration of cases and then
33:42look again at the environmental
33:44factors and environmental controls,
33:45what is the ventilation like?
33:47Do you have access to pee pee?
33:51And if you absolutely have to use C Pap,
33:54try using alternate therapies instead,
33:56like raising the head of the
33:58bed prone positioning,
33:59using oxygen as a bridge therapy,
34:02and importantly in any of these patients,
34:04limit airway procedures and anything
34:07that can increase their civilization.
34:09And then finally,
34:10let's look at mitigating risk
34:12within your practice.
34:13Here we refer to personnel to
34:16facilities and two equipment.
34:18So in terms of personnel,
34:20in order to really mitigate risk,
34:22it's important that personnel have access
34:24to educate their well educated or informed,
34:27and they know what's going on,
34:30and so that means educating
34:32personnel about you,
34:33know screening symptoms,
34:34hand washing, physical distancing,
34:36how to recognize if they have symptoms.
34:39And and what are your facility
34:41sick leave policy's?
34:42When should someone go to employee health?
34:45Make sure that they are aware of how
34:48to put on and take off paper suits.
34:51How do you decide which type of PP is
34:54appropriate given what you're about to do?
34:56So a high risk exposure may require
34:59higher levels of pbe than something
35:01that's a lower risk exposure and
35:03then look at availability of PP.
35:05Make sure that it's available before opening
35:07up services that you can protect your staff,
35:10and if someone is exposed then look at
35:13employee health and what is their guidance a.
35:16When should the person be tested versus
35:18Self Quarantine at home and isolate?
35:20Should they continue to report for work
35:22and what are the criteria for that?
35:24One is a safe time to return to work?
35:27And if someone one of your
35:29staff has symptoms,
35:30make sure that they know that they
35:32should not report to work under those
35:34situations and make sure the lines
35:36of communication and all these policy
35:38changes that are clear and open in fact,
35:41consider setting up regular,
35:42ongoing recurring meetings so
35:44that everybody is on board.
35:46Now the ASM recommends that the patient
35:48to technology ratios that you should
35:50have one technician to every two
35:52patients under usual circumstances.
35:54If you're doing, it in lab sleep study.
35:58But the guidance that we offer
36:00suggests that COVID-19 concerns could.
36:02They're not usual,
36:03they could be considered unusual,
36:05and so you think about whether
36:07other ratios are appropriate,
36:09and some of that may have to
36:11do with local prevalence,
36:13technologist factors.
36:14They may be some text who just don't feel
36:18comfortable taking on more than one patient.
36:21And so there are a lot of other
36:23criteria that need to go into into play.
36:26Sometimes you know during peaks
36:27of activity we actually had text.
36:29Who were you could have text to
36:32or furloughed text her out sick or
36:34who got redeployed.
36:35So make sure that the ones that
36:37are there they may be taxed.
36:39They may be doing other activities like
36:41onboarding patients in Tele health,
36:43so under that that type of stressful
36:45situation make sure that the workforce
36:47that you do have has access to
36:49adequate rest breaks and that sick
36:51leave policy's for them are flexible,
36:53that they're consistent with
36:54public health guidance, and that.
36:56Your fat,
36:57your employees actually know what
36:59they are in terms of the facility.
37:01Think about how can you promote social
37:03distancing inside your facility.
37:05So Tele medicine obviously is
37:07a great way to do it.
37:09But then,
37:10if you're offering in person services,
37:12look at your layout.
37:13How can you avoid crowding?
37:15What preemptive strategies can you
37:17take where you setting up your chairs?
37:19Use distance markers?
37:20Avoid pileup of patients and
37:22check in and check out areas.
37:24Make sure sanitizer and PPER available.
37:27And that there are signs everywhere
37:29reminding patients and staff to to have their
37:33masks on and then talk to your building.
37:36Environmental control staff About Air
37:37Quality and what type of ventilation
37:40and filtration systems are in use.
37:42And is it possible to even consider using
37:46outdoor spaces for providing education
37:49sessions or for dispensing equipment?
37:52And then make sure you're looking
37:54at CDC recommendations for cleaning
37:56and disinfecting equipment in rooms
37:59and manufacturers themselves can
38:00offer cleaning information about
38:02equipment as well as the CDC,
38:04so the other question that comes up
38:07with equipment is if a patient had
38:10COVID-19 UC pap and then recovered,
38:12what should you do with the filters?
38:15And is there a risk for reinfection?
38:18We we don't know with certainty that
38:21there's zero risk for infection.
38:24So our suggestion was that there
38:26basically low-cost items to replace
38:28filters and tubing and so forth,
38:30so we recommended that once full
38:32recovery is taking place,
38:33that everything is is is is replaced,
38:36but the data on reinfection or right
38:38now seem to suggest there is not robust
38:41data that suggests that reinfection
38:43is possible is definitely happening,
38:45but we are also still relatively
38:47early in the pandemic,
38:48and as time goes on an immunity wanes.
38:51We may start to see some cases.
38:54It is clear though,
38:56that after two to three months,
38:58you romantic bodies do tend to wane,
39:00but it's thought that memory T
39:02cells still persist and offer some
39:04level of protection.
39:06In South Korea,
39:06there was a series of 284 cases
39:09that had a second positive test
39:11sometime within months two and
39:13three after symptom onset.
39:14However,
39:15in those patients they were not
39:17able to actually grow live virus
39:19from any of their registry isolates,
39:21and there was no transmission
39:23secondary transmission.
39:24Two 790 Contacts that were traced at
39:26this later time point and there were
39:28a subset of 23 patients who had serum
39:31drawn before and after the retest,
39:33and it turns out 96% of them
39:35still had antibodies.
39:36So at this point the evidence
39:38is not strong for reinfection.
39:41So I want to thank the COVID-19 Task Force.
39:43We've had an amazing group that
39:45works extremely hard and I thank
39:46you for your attention and I'm
39:48happy to take any questions.
40:03Do people need to be unmuted?
40:05Does anyone have their hand raised
40:07you so much for a wonderful talk?
40:09If anyone wants to put questions
40:11in the chat, you can do that.
40:13Or if you want to just unmute yourself
40:15so you can ask questions directly.
40:18Indira, please feel free to
40:20share what you were doing.
40:23If there's something you figured out,
40:26this is your chance.
40:28So from you.
40:29So Indira, the ASM
40:31looking at the the long haulers,
40:34the patients that have symptoms related
40:37to sleep that are just not going away.
40:41I I'm not talking about sleep apnea
40:44now I'm talking about patients who had
40:47Covid who continue to have symptoms
40:49of all sorts, many of which involve
40:52sleep. Yeah, I think that's a That
40:54is a great great point and I think
40:57it's one of the many areas where we
40:59need increased research activity.
41:01I believe there are groups that are
41:03tracking what's happening longitudinally
41:05with some of these kovid patients.
41:07I can't tell you who they are, but I.
41:09I mean, I know New York has
41:11had huge spikes in activities.
41:13There's probably a great cohort
41:15to follow there as well as some
41:17of the other cities that have
41:19had major spikes in activity,
41:20but I think that's a great point.
41:24You know the other aspect of this
41:26is that when you look at immunity
41:28and you look at this hyper immunity,
41:30the hyper immune reaction that
41:32people are talking about in the
41:35cases with severe COVID-19.
41:36You know, sleep is a major
41:38modulator of immune function,
41:39and so we really should be doing crossover
41:42studies between sleep and immunology.
41:43There are a lot of research questions that
41:46come up here that need to be addressed.
41:52But yeah, sleep disruption and what
41:55happens to sleep apnea with chronic lung
41:58damage and with the level of hypoxemia?
42:01Yeah, so send up needing oxygen, yeah,
42:03so there's one group of patients
42:06that I have seen have developed
42:08a fear of falling asleep.
42:10Who who don't actually have.
42:13A reason for it,
42:15they they just developed a fear.
42:17Falling asleep.
42:18Lot of patients have nightmares
42:21that they've never had before.
42:23And interesting, Lee enough.
42:25There's another group of people that
42:27I've encountered who are actually
42:29sleeping a lot more since Covid, Ann,
42:32and it's kind of interesting is that
42:35they say one of the reasons there
42:38kind of sleeping is to kill time.
42:41They're incredibly this,
42:42especially students.
42:43They're incredibly bored,
42:44and they wish that their life would,
42:47you know,
42:48go into Fast forward so they can get over
42:52this thing. Wow.
42:53So there's a lot of interesting
42:55stuff out there that we just don't
42:58know much about. Yes, I agree.
43:00And also with Tele work and what
43:02that's done with schedules and the
43:04opportunity for a later start in
43:06the morning has it actually helps
43:08some of our delayed sleep phasers
43:10have less misalignment and less a
43:11little bit less sleep deprivation.
43:13Yeah, there are a lot of
43:15really good questions.
43:16I've also heard about the possibility
43:18of Kleine Levin in some of our
43:20patients because of the, you know,
43:22any acute viral illness can
43:24precipitate that sleep disorder.
43:26So I think that you know the coming
43:28months and years we're going to
43:30be able to take a Fuller tally
43:32of the impact this has had on our
43:34population in terms of sleep health,
43:36yeah.
43:38For anyone interested in finding out
43:40more about the types of Covetous and
43:43which one is appropriate in your practice,
43:46we have a great talk.
43:48The ASM virtual sleep meeting
43:50happened at the end of August and
43:52Romy Hoque did a really wonderful
43:55synopsis of Cove in testing,
43:57so I would refer anyone who's
44:00interested to give it a listen.
44:03I'll just read out there's a question
44:05in the chat Endura from current
44:07Johnson at Bay State and she asks.
44:09She says we're testing patients
44:11prior to in lab testing for patients
44:13who have had kovid in the past.
44:15Since they may be positive
44:17for a long time on PCR,
44:19do you think that if they come in for
44:22a sleep study two weeks and symptom
44:24free later that they can be
44:26done without extra precautions?
44:27What about if they had kovid three
44:29or six months ago? Would you retest
44:32them at that point?
44:34Yeah, so thanks Karen.
44:36That's those are great questions.
44:37And yeah, I think the CDC
44:39changed their recommendation in
44:41originally with milder cases.
44:42There were two ways to determine
44:44when somebody had recovered.
44:46One was a test based strategy,
44:48which means you had two tests at
44:50least 24 hours apart before they
44:52can be deemed to be clear of virus
44:55and the other ways is if they were
44:58symptom free for 10 days and so you
45:00can you can use the symptom based
45:03strategy for the milder cases.
45:05For some of the people who
45:07have chronic illnesses,
45:08they can take longer to clear the virus
45:10and have persistent positive tests.
45:12It's hard to know if they have a
45:14positive test is a viral fragments or
45:16if they are sick with many comorbidities.
45:19Is it that it's lingering and that
45:21they potentially could be infectious?
45:23So I think those needs,
45:25and when is the window of time when
45:28someone clearly can be considered recovered.
45:30So these are all nebulous questions
45:32and we talked about it in our group.
45:35I would say consider an ID console.
45:38In fact,
45:38if you if you have a question and as
45:41far as antibodies response waiting,
45:44I think that it's thought that
45:46up to three months they may be.
45:50Protected,
45:50but once you start getting outside
45:52that six month window then we don't
45:55know and even within the three to six
45:57month window, we just don't know,
45:59but we haven't seen it,
46:01though we haven't seen a robust relapse
46:03rate or every infection rate rather,
46:05but relapse.
46:06It is possible if they never fully
46:08recovered the first time and they could
46:11still have the ability to relapse
46:13and potentially become infectious again.
46:15So yeah,
46:16I think will Carnes doing is pointing to.
46:19If someone tests positive,
46:21are they infected or infectious?
46:23And that's a really important distinction.
46:27And so antibody testing it's it's
46:30not thought to be fully useful.
46:34So it really is a clinical question
46:36and this is really for the patients
46:38who have moderate to severe
46:40disease and they are in a high
46:42risk group with many comorbidities.
46:43But the ones who are healthy have mild
46:46cases can be declared free once they are.
46:49Once they haven't had symptoms.
46:52Or 10 days or more.
46:55I
46:55classic question I see anywhere are
46:58you doing great talk? Thank you so
47:00much so question and observation.
47:02You know that study that you quoted
47:05regarding the covid virus still being
47:08on the various forms of materials and
47:11that's kind of what upset the basis for
47:13the three day recommendation that study.
47:16They didn't actually clean the
47:18materials after they re test it right?
47:20So that was that was just.
47:23So we're cleaning our studies.
47:25You know, so presumably there
47:27should be no no virus on there,
47:29but I don't think anyone is
47:30specifically studied that like I
47:32don't you know whether or not the
47:33cleaning how effective the cleaning is.
47:35I guess I sort of understand that,
47:37but that's sort of a little bit of
47:39something that's been an issue with
47:41us 'cause we want to get turned over.
47:43We had a big backlog of studies
47:45and we want to get them through
47:47in the three day recommendation.
47:48I kind of really slow things
47:50down a little bit and then just
47:52an interesting observation.
47:53I'm wondering if anyone has experienced
47:54this in their level Greece studies.
47:56We constantly cleaning these belts
47:58'cause the belts are really one and the
48:00device itself were not really reusable
48:02whereas we throw out the cannula.
48:03I could throughout the pulse ox
48:05but the belts have to be cleaned
48:07and as well as the device and our
48:09text to a lot of job in pushing the
48:12cleaning this stuff in the belts and
48:14we've noticed that we've actually
48:15lost a lot of the efforts.
48:17Signal the effort signals are not as
48:18good as they were before and we've
48:20gotten the machine was sort of fooled
48:22into thinking that there was central
48:24apnea when there really wasn't central
48:26apnea and and I'm just wondering if
48:28anyone has noticed that on there.
48:30On their home studies with the effort
48:31belts from the frequent cleaning
48:33could have an impact on the quality
48:35of the effort signal that we get
48:37from the machines in this morning.
48:38If that's been an observation for many one.
48:41Yeah, that's a great question.
48:43Would anyone like to respond in
48:45the chat or? Unmute yourself.
48:48We haven't seen that so far in OK,
48:52but it might also depend on if you own
48:55the devices versus if you rent them and
48:58and send them back and started after.
49:02Right, yeah, we we own the devices to
49:04work constantly turning him over as
49:06quickly as possible and so it's just
49:08I've had a few cases where, Oh my God,
49:11this looks like central apnea,
49:12but the patient does have any risk
49:14factors for central apnea and we
49:16really go over to finally tooth comb
49:18and I think it's not central apnea.
49:20I send them for diagnostic and
49:22it's all obstructive. No central.
49:23So the other thing to consider is patient
49:26education during setup and how many
49:28of them are not being rigorous with
49:30the positioning of the belt so that
49:32it's just a little bit misplaced, or.
49:35You know, because it can be really a
49:37function of of where on the Thorax,
49:39where on the abdomen, and sitting.
49:42Yeah, these are things that I think
49:44that it's going to take a lot of
49:46troubleshooting to figure out.
49:47Maybe try wearing it yourself, right?
49:49So so I will definitely let
49:51I'll give it three days before I put it
49:55on now, definitely. There
49:58are disposable belts that
49:59are available though. Yeah.
50:02Right, we looked into that.
50:03I think it was just an
50:05added of disposable costs.
50:07Reduces the bottom line.
50:08But yeah, I think that's
50:10something to consider. Very
50:12well, we're at the three o'clock hour,
50:14so I think we'll wrap up and I
50:16just want to let everybody know
50:18the information about the CME.
50:19Login is now in the chat.
50:21If you didn't see that early on,
50:23click on chat right now and you have
50:26until 3:15 to get CME credit for this.
50:28And please join us for next week.
50:30We have a talk by Lauren Hale
50:32from Stony Brook University.
50:33She's going to be speaking about racial
50:35disparities in sleep health and thank you
50:37everyone for joining today.
50:40Thank you, thank you.