State_sleep_2020.04_29

April 29, 2020

ID5115

To CiteDCA Citation Guide

00:00The The future of Sleep Medicine.
00:02The future sleep clinics and actually Andres in truck was supposed to be doing this introduction,
00:09but he's been called away to the intensive care unit and he's working nights a van and anyway,
00:16so I'm gonna introduce current.
00:18I just want to say the way this thing involved is that a few of us were kind of emailing each other about.
00:27What's going to happen in the future with the sleep,
00:31clinics, and so forth and and we said,
00:34well, maybe we should go ahead and an arm should organize zoom session to go over this and get input from various people.
00:44So for those of you who don't know a carne,
00:48she's an associate professor of neurology at UMass.
00:51She went to an obscure College in Cambridge,
00:55MA, then went to University of Chicago for medical school.
00:59Did her in internal Medison and neurology at Brown and then her fellowship.
01:04She did her Harvard and sleep Madison.
01:08So Carne, once you go ahead and
01:11and start the
01:12session. Thank you, um, and I'm just trying to get my chat of field over here.
01:22So overall, even though this is,
01:26uhm, entitled, uh? Uh, a post pandemic sleep lab.
01:31It's actually probably more better to be called a during the pandemic sleep lab,
01:37and we really want to.
01:39You know, talk about what to do next at this point.
01:43Can you get my slides to move forward?
01:46Uhm, so uh. First of all,
01:49uh, you can get CME credit.
01:51You have to be signed up on the LC me,
01:55but here's the code for those who are 14426.
01:58Um? We have gotten disclosures from our panel that I'll introduce you to um or speakers and then we also have piano today,
02:10but overall there's no conflicts of interest.
02:12So the way we're going to work today session is a few of us are going to give some brief presentations.
02:21I'm going to talk about some mitigation strategies and what are the thoughts around opening sleep labs doctor came apart is going to.
02:31Touch on how Pediatrics fits in.
02:33Then Doctor Thomas about the care of some complex sleep patients and how to do things management wise without sleep studies.
02:43And then we're very happy to have doctor new Nas and doctor white to comment from Respironics and res Med related to.
02:54Where things are from manufacturer side,
02:56we're then going to hopefully have time for questions and we are going to keep this line open till 4:00 PM if needed for panel of people to ask.
03:07You know, measures measures so please.
03:10I send in chat questions and we will try to get through as many as we can at the end of things.
03:18So, uh, Peter gay. I just found it may not be joining us,
03:22but uh. Again, we have Carlos Nunez and actually,
03:27I don't have confirmation with David White,
03:30so I gotta make sure we get him on the line with us.
03:36And then in Dera. Google.
03:40Um and Doctor Sullivan are helping represent the ASM Public Safety Committee has been putting out there guys guidelines and recommendations.
03:51Doctor Ken apart from the Ellen getting to give insight under Pediatrics and Doctor Thomas Edison will be talking about.
04:00The speakers, so where we are today.
04:03ASM at the beginning of April put out an initial statement on mitigation strategies with covad,
04:10which basically suggested, given the federal guidance to maintain the social distance that unless it was emergency to pretty much shut down all in person both clinic visits as well
04:24as lab studies. And if they were to be done that they should be done under precautions.
04:32So just Monday they put out a new statement.
04:39Let me see if this is one of my speakers calling in hello.
04:44Hello. Oh, hi, I'm sorry this is Peter Gay.
04:51I'm starting to talk. Can I get you in your oh you're totally locked up from joining?
04:56OK, um, I don't. I think we're at the limit so I don't know if there's anyway.
05:04I can leave you on the phone or.
05:09To leave him on the phone on the phone if you can hear it uhm so overall.
05:17But again, there is, uhm.
05:22Uh, some stand up, sorry.
05:25Yeah, they're they're overall recommendations.
05:27Uhm, related to reopening really depend on what is happening in the community.
05:33So if the community transmission is at substantial levels than to really stay closed if the community transition is more at the minimum of moderate levels to think about reopening
05:47specially those studies that don't involve pap titration zan also not patients.
05:53That would be a large risk if they were to get out of it,
05:58but to still think about holding off on pap titrations,
06:01unless it was an emergency,
06:03and then for no or minimal transmission,
06:06that would be the point to basically resume studies as before.
06:10Hum. Forward so they also commented on that path.
06:16Titration is considered procedure with a higher risk of aerosol transmissions and to use appropriate PE and basically to follow the CDC's transmission based precautions.
06:30So a couple of questions that I still have related to these.
06:36How about these recommendations and sort of the areas that there still are questions,
06:43and again, I recommend you all go to the ASM website for the full descriptions is who is an emergency patient and personally we've had quite a few patients who
06:58still cannot get devices without studies.
07:01Medicure as hopefully most you know has approved the ability to get devices without studies.
07:08But if they need more advanced devices like I've apps or ASV,
07:15we found that D me companies.
07:18Some of them have been unwilling to.
07:22Give them out. Even to Medicare patients,
07:25for fear of potentially audits and that they won't eventually qualify when the studies are needed and the other big question is,
07:33you know, what can we do empirically?
07:36I think a lot of us have been switching patients that were ordered in in lab study to home safe studies,
07:44ones that we would have liked.
07:47The titration for two. To to to to to see pap or auto Bipap.
07:52But I think there are patients that do hit the limits where we still feel we really need that study and I certainly have patients in semi list that I
08:03know I am worried that if we put of-
08:06care for another month or two months or for an unknown period of time that it might lead to them getting re admitted or having some other adverse outcome.
08:16Other question is what is a proper pee pee?
08:20In some cases it's very clear if you have a Costco big positive patient that you really felt you needed to do,
08:30we would very clearly need to do that under airborne precautions and inappropriate room.
08:36But what if it's presumed negative?
08:39You know what if we screen them out and ask them questions?
08:44Do do? Do those patients need?
08:47To be under the same PP and and room precautions.
08:50And then what if we do have the negative viral testing?
08:55Does that put us in a place where we feel that no special precautions are needed?
09:01So I just want to review Watt.
09:05We kind of know about the transmission over all the incubation period for Chobit is about five days,
09:13but the ranges anywhere from about 1 to 14 days and there's a difference between the window of viral shedding,
09:22which is thought to be from about a week prior to.
09:27Um? To symptoms as shown in this graphic here by the black dots and it can go actually out to around 21 days.
09:39After someone presents with symptoms that virus still can be found on PCR testing,
09:44but different concept of the window of infectivity,
09:47which is basically as when is there viable virus that can reproduce and grow and culture and so the red dots on this upper graph show that from about six
09:58days prior to symptoms to about nine days after symptoms start is when it's thought that people have virus that key and transmit and that the peak is actually about
10:09one to three days before symptoms so.
10:12Obviously that puts us, you know,
10:14in a big worry of,
10:16even if we're screening patients for fever and other things,
10:20are they truly? Um? Alright,
10:24I do. They really not have to bed or in this stage that they can still give disease,
10:30spread the virus so it is that most of the spread is not to be pre symptomatic people that will end up having disease and it's a little less unclear
10:40if they're asymptomatic. But again from our standpoint of you know we have a person who wants to come to lab.
10:47We don't know what they're going to be a week down the line.
10:51We do know that there are,
10:53especially in certain communities, very high rates of asymptomatic people.
10:56So in Washington nursing home study,
10:58they found 56% of the people that were pissed PCR positive had no symptoms at all.
11:04And then an interesting study at in New York where they just started testing every single woman I was coming in to have a baby.
11:13They found about 15% of people were positive but less than 2%
11:18of those had symptoms. So on the other end,
11:22you know if we do test someone,
11:25can we trust it? So in general,
11:28most of the tests out there have been.
11:31Said to have about a 95%
11:34sensitivity which is felt to be very good now in some unpublished data from doctor prokop pick Cleveland Clinic,
11:42he took known positive samples and retest them with a number of tests and most test still were good up in the 95 plus percent range but but there was
11:56some variability including one test that came out only at 9885%
12:00sensitivity and so really bringing up.
12:03You know the question of you know,
12:06are all these tests the same?
12:08In terms of, you know,
12:11is it playing out in real life?
12:14For this sensitivity there was one report by Richardson in New York City where they found that 3.2%
12:23of patients out of 5700 patients.
12:27Had a positive first task but.
12:31But three point 2%, it only was positive on the 2nd test,
12:36so that is in line with about the 95%
12:40sensitivity. Now there's the other concept of clinical sensitivity.
12:44Are is it as good picking up real life patients which obviously has to do with how you're swapping them,
12:51how sick they are, how much virus they have in their in their in their upper airway and nose or saliva.
12:58And so one study out of China.
13:01They compared people with positive CT scans consistent with ours,
13:05and they found that the peace TR only picked up about 6680%.
13:09So that brings up what is the gold standard?
13:12Overall, the gold standard right now for who is positive.
13:16Is the PCR test, but but maybe maybe it is and maybe it misses people so there's alot unknown but I think the comforting thing is the thought is if
13:28you have an asymptomatic patient there is a very good chance that even if they do have coded they have so little of it.
13:37If they have a negative task that it's less likely that they can spread the disease.
13:44So the other question is how does this Cove in transmit and the general thought for the most part,
13:51is that it spread through contact and large droplets,
13:54which is why basically if we stay the six feet away from people,
13:59we are very unlikely to get it.
14:02And if we are within that six feet range we can use just contact precautions and there's a number of different studies that are reports that sort of go in
14:13that direction or not. There,
14:15uhm, but but some are little buried,
14:18so a couple of studies want encoded one,
14:22and stars felt that there was not any aerosole spread.
14:26Then there's a number of studies that do think there's possible spread.
14:31One of note is this study by Santarpio and they put.
14:36These sort of collectors around patients rooms and they found that about 63%
14:41of the air samples that they collected from around peoples rooms in somewhere near the patient were still positive with PCR,
14:49so they were suggesting that it potentially is spread in the air.
14:54Now this study did not look for the viability of that virus,
14:59so it's possible that you can pick up viral particles in the air,
15:04but it doesn't necessarily mean that those are transmissible.
15:07So there are some expert warnings that do you know,
15:12state that, specially with certain procedures that are more air sizing that we should be worried.
15:19But again the data is not the strongest,
15:23so it's really we don't know what the CDC really says is 2 of the main studies that they based their recommendations on as related to non invasive ventilation,
15:37possibly spreading. Disease is really these health care workers.
15:41Studies with stars, and so the top one they found that 38%
15:46of workers who had been exposed to non invasive ventilation versus 17%
15:51workers were not exposed with noninvasive ventilation ended up contracting SARS and then a second study that found about 2.3 relative risk that the health care workers contract it's ours.
16:03If they had been exposed to bypass.
16:06But again these were not.
16:08Clean studies by any measures these patients you know somewhere on Bipap and other modalities,
16:15and had other potential reasons why they might spread noninvasive ventilation.
16:20So what meta analysis of the pooled results of those two studies came out with a 3.1 odds ratio,
16:28and then I found one further study where they looked for case warrants that had super spreading of SARS versus case words without super spreading,
16:37and the words that use bilevel ventilation had almost a 12 times higher risk for spreading.
16:43Sorry, so again, I think you know there is a reasonable reason to based on some of these studies to think.
16:51That health care workers could be exposed and more at risk with.
16:57Non invasive ventilation. But what do we know from sort of lab studies?
17:03So there's these two studies that basically show if in a lab and sort of under control settings that there's no more in about a one meter spread of droplets,
17:15again consistent with sort of context bread,
17:18but not not the small aerosol spread and the first study even tested people with active influenza and with symptoms and still did not find any change.
17:30Um, another set of sort of lab based studies were done by Huey and.
17:36China, Anne he Interestingly tested different types of mass to see what the air dispersion was.
17:42So he mixed in smoke with the air and looked for the spread of that and the sort of the oxygen therapy by nasal cannula and some of the full
17:52face mask that had a sort of large single exhalation port had the largest spread,
17:58but still no more than a meter.
18:00Interestingly, the Quadrel Air Mask had no measurable dispersion of air,
18:04and they found it was due to the multiple small.
18:08Exclamation points, which is sort of more standard with a lot of our newer mass today.
18:16Um, I'm going to refer you to a yells.
18:19Lastly, grand rounds up if you want more information on this,
18:23but Doctor Krieger and Thomas proposed using a non vented mask with a viral filter followed by an exclamation point in order to sort of filter out the virus before
18:34the air escapes. And you know,
18:36I think that can be a mitigation strategy to be used.
18:40However, one issue is that if there is a leak around the mask you kind of negate the issue so.
18:47You do want to make sure you can have a good fit with the mask.
18:54Um, another UM thing is related to the isolation rooms.
18:59Is this bottom reference here from Minnesota list some different methods to basically essentially make a negative pressure room using things like help,
19:10HEPA filters and other equipment so for people who feel they need those error isolation rooms,
19:17there may be some ways to sort of make them.
19:22No, this this bottom picture here.
19:24I did find one patent for a device that is essentially what a doctor,
19:30krieger and Thomas were proposing.
19:32So some other possible precautions on the latest ASM recommendations.
19:37They recommended things like checking the patients temperature on arrival,
19:41checking the text temperature twice daily,
19:44having patients not sit around in waiting rooms.
19:48Some other potential ideas are checking oxygen saturation's on arrival,
19:52and if they are low and that's not what you're expecting from their baseline conditions,
19:59that can potentially suggest. Respiratory symptoms,
20:02potentially using one on one text.
20:05If you are using. APPE using donning and dolphin coaches to make sure it's used appropriately,
20:12potentially limiting titration studies only to certain you rooms or using disposable supplies for those studies like in this picture here,
20:21potentially having a filter on the device end of the tubing in order to at least try to keep any contamination out of the machines themselves,
20:31and then what to do with cleaning procedures.
20:34Do you need to wait for an hour before the cleaning?
20:39People come in and clean,
20:40or if those rooms are being used in the day,
20:44do you need to wait,
20:45wait for that and then is there any other special ways to clean the room and especially kind of within that that one meter of where the path is being
20:56used? So overall you know all these things,
20:58uh, whether you can do him or not.
21:01It really partly depends on availability and supplies.
21:03So obviously the testing capability of the PP ability are two of the biggest in terms of supplies and then you know some of these other things is what is
21:13the cost, and is it doable?
21:14And as it is it worth it to try to be able to take care of any of these patients before things really change in your area.
21:23Some other issues that I know certain people have is a lot of text,
21:27specially if their respiratory therapist maybe.
21:29We deployed and are you able to get them back at this time and you have plans if attacks only does go out on quarantine and can you replace them
21:38during that period and then you know,
21:40especially pulmonologist may be redeployed.
21:42So you have enough people to read your studies.
21:44Some other issues I've heard about are related to lab space,
21:48so I know some labs have been had their space taken over and is now a Cove in unit.
21:53Or maybe you have to walk through the code unit to get to the lab.
21:58So is it really feasible to?
22:00Bring out patients into a setting like that and then you know what is the ventilation systems you know.
22:05If you're out in a hotel versus a hospital,
22:08or you know whatever the setting is is,
22:10you know. Do you know what the ventilation system is and is that shared and will that change what you're able to do?
22:18Um, so again, just to summarize,
22:20sort of. What's the right time I think you know what the local levels is.
22:25The number one thing you might be able to change what you're able to do if you do have that viral testing capacity and you have PP availability.
22:34But then there's always, you know just what is the risk management issues.
22:39What happens if you do?
22:40Do you know a patient?
22:42And then they come down with Cove it a week later?
22:46You know, you know, do you feel that you potentially be at risk if something like that would happen?
22:52And then if you're in a hospital,
22:55what are their infection regulations?
22:56You know you may want to use PPA,
22:59but they might say you know you can't or or vice versa.
23:04So I think all those things really matter.
23:06So I'm going to now Passover to doctor Khanna,
23:10Pari and I'm going to.
23:12See if I have. What we need to do for unmuting him?
23:21Uhm, I think you're awesome.
23:25Car and thank you very much.
23:27I'm just going to go quickly.
23:30Like you guys we are dealing with many of the same issues but specifically in the pediatric side because for whatever reason children are much less affected by Kovid then
23:40adults we are dealing with.
23:41The fact that a lot of this sort of resources in space in the hospital is being hoovered up for the care of sick adult patients,
23:50so his car and just said one of our satellite labs is now an adult unit in our main lab at Yale.
23:57New Haven is in a hospital floor.
24:00It is now a cogan floor,
24:02so we are thinking about issues like how can we safely bring in family members in patients without without exposure triage.
24:11Ng is certainly an issue.
24:13We have a high proportion of medically complex patients coming into the lab,
24:19just like like an in lab studies for you guys.
24:23Those patients tend to need studies more,
24:26more urgently, but. They also are higher risk,
24:30so how? What is the best way for us to triage them?
24:34We've actually been thinking a little bit about in our lab about starting to utilize some home sleep testing,
24:40which we've been reluctant to do.
24:42It isn't really recommended by the ASM right now for children,
24:45but at least for older adolescents as a way to sort of short and our wait list heading into this pandemic,
24:52we had a three to four month wait list,
24:55which is only getting longer as were as well.
24:58So on, and we're going to have to kind of re triage every based on the best infection control practices which are really unclear and also urgency.
25:08The only studies we've been running lately are impatient studies,
25:11specifically in the neonatal ICU which is considered to be a clean unit.
25:16We're talking at our hospital about viral testing,
25:18and if you've had one of these done,
25:21it is a deep nasopharyngeal swab,
25:23sort of like if you ever done a pertussis Schwab,
25:27and when we have anxious kids coming into the lab were already worried about the study.
25:32In the setup, is traumatic,
25:34were kind of priming them for a bad experience by swapping their nose,
25:39although we are leaning Tord's at our institution,
25:42doing that, at least in the short term we starting up.
25:46Our lab has a really small footprint,
25:49so we are thinking about,
25:50well, how many patients should we actually bring into study.
25:54We have a shared bathroom in our main lab,
25:57the one that's not occupied.
25:59Bible patients from manage that.
26:01Um, testing for parents is also a thorny area who's going to pay for testing for parents if someone comes into my office and we do a strep test,
26:11we don't check the parents.
26:12We don't usually check the siblings either,
26:15so it's going to kind of come down to one of the players going to say about this from the hospital.
26:21Let us do it. And finally again,
26:24the optics of it. What will happen to patients were already anxious,
26:28have text and full PE.
26:29We want our patients to have a good experience and we get a better sleep study if they're not crying hysterically for half the night.
26:37So we have to balance safety,
26:39but also the patient experience,
26:40and perhaps a way that you don't have to in
26:43a in an adult.
26:48Alright, thank you um and let me see if I can get to the next slide.
26:55We're going to pass off the Doctor Thomas.
26:58I believe I have to unmute.
27:02Um? Let me see if I can find me here.
27:09First, now it's not letting me search for him.
27:18Oh, come on. Not letting me share stuff participants for Robert anymore,
27:37um? See if I can find him.
27:45Sorry. Well, I'm trying to get him
27:56up doctor need as I got you good.
28:08So can you move the slides for me?
28:11I realize I don't have this on my computer,
28:13just tell me when. Alright,
28:16so. The
28:18idea here is to very quickly.
28:21Talk about how we can manage patients who have.
28:25Uh, the whole range of sleep disordered breathing without having titration studies.
28:31Obviously we need some kind of diagnostic assessment.
28:34Zoom here for now that we have at least.
28:38Oh home sleep test. Uh,
28:41an perhaps you wanna diagnostic PSD,
28:43which we managed to get before the.
28:46Covert struck. And the phenotypes of concern are obstruction.
28:52High low gain. And here this in compasses central,
28:56sleep apnea, periodic breathing, complex apnea,
28:58colored. Or do you want?
28:59But you have respiratory control instability?
29:02And of course your hypoventilation.
29:05So you recognize, uh, to the keys to recognize this.
29:09An obstruction is fairly straightforward
29:11where you have. Rim dominant variable cycle events.
29:15If
29:15it's a home study, you would see a V shape.
29:20The saturation. I'll show you pictures of all these very quickly.
29:27High low gain uh is non dominant self similar events.
29:32Oh, periodic breathing in some form of the other.
29:35And the desaturation profile is more like a belt or a band,
29:38because the events are self similar.
29:40Hypoventilation may be harder, but if you have a disproportionate on resolving hypoxia,
29:46assuming one can get home oximetry.
29:50Either the patient does it or is it done by DMA company.
29:54Uh, and uh, at least out here in Boston we have the option of doing home capnometry Not right now,
30:01but certainly once we open up a bit more next slide.
30:07Who? Thanks, very good.
30:10So, uh, whoops, too many.
30:15Yeah. This is OK, so this is an example of high low gain sleep apnea.
30:21Uh, individual events are obstructive.
30:24Uh, as you scold them conventionally,
30:25but when you look at the timing and the morphology of the events,
30:29they're very self similar. There are non REM sleep.
30:32I am on top is a diagnostic part on the bottom.
30:36Is the titration part, where C Pap essentially helps with the obstruction but now exposes the underlying rhythm abnormality.
30:42So this would be a person if you have the diagnostic data would be at high risk of having residual disease.
30:50Next slide. You can get similar information from home sleep.
30:55Study this 2 two samples.
30:57About showing a whoops. About showing I look in the key here is self similar events.
31:06You can see the self similarity in the Platte signal and the timing of events in the snoring.
31:12Pretty much all true. Oh,
31:15next
31:16slide. The
31:18oximetry patterns on top is the V shape desaturations of ram dominant disease.
31:25Uh, essentially nothing else really causes this pattern.
31:27If you see this pattern,
31:29you can be confident that this really is.
31:32A regulated sleep apnea. They may be non room disease.
31:35Lots of snoring and what not.
31:37But this is ram dominant disease.
31:40On the bottom, uh, example is where you have some features of ram,
31:44especially the first study saturation,
31:45but after that you have more like a.
31:49Uh, horizontally self similar belt,
31:50or a bandy saturation? This would be a feature of high loop game with at least some risk of having treatment emergent central apnea.
32:00Next line. This is from,
32:06uh. Watch bad study is showing,
32:10uh, you know, almost pure ram,
32:12dominant sleep apnea with deep V shaped desaturations.
32:16How to then this actual triggering of it'll simulation,
32:19which swings back to sinus rhythm through the night.
32:21So even from a home study we can actually figure out these things.
32:26That makes life so approach to management,
32:28so strategies can be 1.
32:30Uh, you can be reactive by you,
32:32say, well, I'll just start with C Pap and see what happens and if there's trouble I'll take care of it.
32:38Or you can be proactive where you risk phenotype or you risk stratify patients and try to preempt.
32:44Yeah, diagnostic in tracking tools.
32:46You have the visual or mathematical signal analysis.
32:50Uh, if you're gonna be on the cover days for awhile,
32:53there is incentive to actually bring forward into clinical practice.
32:56Mathematical analysis, which has been worked out,
32:59but visually one can make a decent.
33:02A determination the online data.
33:05Uh, can be evaluated as is as an air view,
33:08or. Uh, on core or we can use freeware.
33:12Sleepyhead is now called Oscar open source C Pap analysis report it.
33:17Then you have primary adjunctive therapies.
33:19Of course if you diagnose ram,
33:21dominant OS, AC pad generally works for total appliance or.
33:26You know, hypoglossal nerve stimulation should work.
33:29If you know Halo game sleep apnea,
33:31non supine sleep is important.
33:33You can decide how far you want to go with oxygen loaders.
33:37SF is Olamide. Getting adapter ventilation be quite difficult I suspect,
33:42but certainly it's an option.
33:44Uh, an unvented mask? Maybe home care company will be willing to.
33:48I give a loaner or rent the adapter.
33:50Went later until the lab opens and you get more definite today to.
33:55Life is this big hyperventilation.
33:56Resign says summons on C Pap and has put a sudden hypoxia moving to buy level with a moderate kind of setting or a Webster Wise.
34:06Would be reasonable where you utilize the auto functionality of the volume target ventilators.
34:13If you're persistent, subjective or objective,
34:15sleep fragmentation. One could consider's editors after talking to be able therapy.
34:21Example of what happens when you have a good and bad breathing on C.
34:25Pap on top is. Oh,
34:27you don't agree thing detected.
34:30On the lower left is short cycle,
34:33periodic breathing not detected by the pap device.
34:36And on the right is stable breathing where you'd like to see most of the patients spend most of the nights next line.
34:42Oh, you can use
34:44that space. We use it quite routinely in Boston using about 100 CC.
34:48That space with a non vented mask.
34:51See it goes up at the most wanted to millimeters Mercury,
34:55but it does help stabilize.
34:57Not breathing this before after example here.
35:01Have you done literally thousands of these studies?
35:04Next slide? Estes Olamide a low dose.
35:09We're talking about 120 five 250 milligrams more is not needed.
35:13It can cause it can result in really very good effects when combined with the see pap next slide.
35:22Example of that on top is before Estes Olamide and the same study about an R after taking a single 250 milligram tablets is all my.
35:31I'll be a complete stability.
35:33We have almost well over 300 patients on loaders.
35:36Estes Olamide at Beth Israel.
35:38Uh, and we have a pretty good data which we are putting together.
35:42Of course, with waveforms tracking that this really
35:45makes a huge difference.
35:49And after ventilators, uh, can workout fairly well.
35:52I in a subset of patients with central sleep apnea,
35:56but one must look at the data carefully and this is using sleepyhead software on the upper left panel.
36:03Uh, is uh? Uh, yes,
36:06we working well. The red part.
36:09The red signal is pressure out of the device and there is.
36:13This is a good outcome pressure profile while on the lower right the pressure is flying up and down and you can see a title.
36:21Volume graph is also. Of fairly broadly.
36:26The inspiratory next, but every time variable,
36:28so you can, uh, estimate the efficacy fairly well by looking at this level data.
36:33But you have to go beyond what the manufacturer software shows you next line.
36:41It's OK, it's a pressure cycling with the Phillips says we those little purple blobs are when the device kicks in.
36:49So here you have the device kicking in intermittently and the pressure cycling means the device is responding an it is helping ventilation but often sleep.
36:58Fragmentation remains with such a profile.
37:04Otherwise, may miss events. Whatever algorithm is used to detect can sometimes miss events completely.
37:09This is auto SV is ongoing,
37:11unstable breathing ongoing pressure cycling by the device is not detecting it,
37:16so you have to visually look at it next line.
37:22So this is basically the idea.
37:23You have a data driven approach to sleep disordered breathing.
37:26It doesn't matter where you get the data from.
37:29Weather is a lab study home,
37:31study device variables. It doesn't matter.
37:33But once you establish what the enemy is,
37:35control versus mechanics was asleep.
37:37Individually or in combination with the tools we have now,
37:40it takes extra effort tracking these patients.
37:43I will tell you that,
37:44but you can actually provide them.
37:46You know, pretty good. It won't be quite as good as lab,
37:50but you know pretty good management.
37:52I think that's the last
37:53slide. Yeah. Thank you doctor Thomas,
37:59um doctor. Noon as I think you can unmute yourself,
38:04yes, thank you. Hum so just to uh,
38:08first of all, thank you again for inviting me to participate and just to throw it out there to remind everybody.
38:14Yes, I do work for res Med,
38:16but my goal is to not discuss res Med products or therapies at all.
38:21It really just to give you a generic sort of manufacturers perspective.
38:24For us this began in late December,
38:27so we've been dealing with the code in 19 crisis since it broke out in China,
38:31and we've seen how a lot of the supply chain and manufacturing issues have evolved over the last four months.
38:38And looking at it primarily from AUS lens,
38:41now I just go through some of these bullet points.
38:45The supply chain issues cannot be minimized as you know there is a global demand for devices right now for mechanical ventilation.
38:58And also about Disposables and things which effects the sleep side of this equation because you've taken a backseat a little bit to the acute phase of the.
39:1410 dinner so we are dealing with supply chain issues that are everything from raw materials to components to air freight and then dealing with a demand from the world.
39:26That is saying we need you to make less pap devices and the bilevel devices that you're making.
39:32We need them focus on hospitals and kind of cute response.
39:36So these are there are very real issues.
39:40Um, hopefully now that most of the developed world is either nearing or past their peak,
39:46and we're starting to understand how this pandemic is developing in terms of subsequent or second waves,
39:52where the countries that are going to have their first waves or emerging places like India,
39:58Indonesia, Brazil, Mexico, Nigeria, etc.
40:00and I think the global manufacturing footprint has a better handle on some of the supply chain issues going forward.
40:07We also anticipate that the need for noninvasive and invasive ventilators The demand will start to drop precipitously over the next month or so,
40:17so it should improve supply chain for sleep related devices.
40:20The second point here question how will current and future needs for non vented masks filters another circuit components be met?
40:28I think there is global recognition that the way we conduct business going forward within healthcare will be permanently altered and a part of that is the need for the
40:40accommodations. That car in discussed at the beginning of this conference.
40:44Everything from the way that you.
40:47That outfit your lab to the way that you ratio text to patients to the pee pee in isolation capabilities and circuit configurations.
40:56Doctor Krieger as was discussed and others have worked on a variety of different circuit configurations that help minimize the spread of droplets.
41:04And so I think all of the manufacturers are acutely focused on the fact that in a month or two when the demand for ventilator starts to drop off.
41:15The need for supplies and disposables going forward will will remain at a very high and elevated demand,
41:23especially beyond coded patients and beyond the hospital.
41:26It's sleep labs procedure all sorts of procedure rooms and procedural areas.
41:31Outpatient facilities that are going to demand these types of supplies in Disposables.
41:36And so we are seeing the supply chain ramp up for a sustained and potentially permanent delivery of higher levels of non vented masks abab filters.
41:47Um, in circuit exhalation valves,
41:50events, and things like that.
41:54The third bullet. How can remote patient management be optimized with current platform?
41:58So you just heard doctor Thomas talking about the management of patients when you're unable to rely on and in lab sleep test.
42:06and I think across all of Medison we're going to see the exception to the acceptance of remote interactions with patients continue to rise.
42:14I was on a web and are just a week ago,
42:18I believe, where they showed that it most health systems in the US was single digits.
42:23The number of. A percentage of patient encounters that happened remotely.
42:28It is now more than half of routine patient encounters are happening in some way remotely,
42:36either via email, online patient portals,
42:38video visits, remote management, using software.
42:41All sorts of different approaches to remote patient management.
42:44I think overall the patients in the consumers have grown accustomed to a world of technology that allows them to connect instantly with a lot of different services,
42:54and to do things online,
42:55and I think now in the face of this crisis that they many patients have seen how effective remote management can be an remote engagement with their providers.
43:06Can be we're going to see maybe a drop off,
43:08but it will never drop back to the single digits.
43:12The health system where I used to work before I joined industry.
43:16I stay in contact with a lot of my colleagues there.
43:20They were doing a few 100 video visits a week and now they're doing thousands a week and it continues to climb.
43:29So I think within Sleep Medicine there is a lot of opportunity to think about the future and how home sleep testing in lab sleep testing and remote patient management
43:40come together to virtualize care where it makes sense.
43:43To move Karen, move the things we do closer to the patient and then use the data as doctor Thomas mentioned,
43:51the more data and the more data sources you get,
43:54the better that you can manage those patients.
43:57Also, sorry I'm seeing some questions coming up for me in the chat,
44:01so I will get to those in a second.
44:04Let me just get through these last couple bullet points.
44:07I think I just mentioned data data from connected path devices data from our patients from other modes of care as they enroll in digital health platforms going forward.
44:16As more and more patients where wearable devices,
44:18we're going to have a constellation of data.
44:21We're starting to see around the world governments implement things like contact tracing and tracking of patients who test positive for kovid.
44:28And the resistance to sharing personal information,
44:31location data healthcare information is actually dropping precipitously.
44:34You see in Australia, for example,
44:36the government lawsuit launched a contact tracing app.
44:39They were expecting half a million signups in the first week.
44:44They got 1.6 million signups in the first 5 hours,
44:48so we're going to have opportunities in Sleep Medicine to virtualize the Karen to stay connected with patients more than we ever have before as the virtualization of healthcare gains
44:59greater acceptance. I think we talked about resupply a little bit when we talked about supply chain.
45:06I believe that all of the manufacturers of the supplies in the disposables use in respiratory care on the outpatient side,
45:14especially around sleep. Madison are ramping up for a world where higher levels of supplies and disposables,
45:20especially around non vented Masson filters.
45:22As I mentioned are going to be required.
45:25And then Lastly we've seen some alterations to payment and reimbursement policy,
45:30the ability to. Prescribed devices without a sleep test for example,
45:34and still expect reimbursement is one thing that's changed temporarily under the code 19 crisis.
45:41We've seen some relaxation around Telemonitoring and telemedicine codes.
45:44An reimbursement policy? How much of that will persist after the fact?
45:49How much will the New World of Medicine.
45:53That becomes increasingly virtualized also adopt payment and reimbursement policies that make it more likely that we can sustain those types of policies.
46:02I think in the end from the manufacturers perspective,
46:05right now everybody is. I would say mostly head down head down trying to deal with the global demand for devices mostly on the the by level and the invasive
46:15vent side. But we will see that demand start to decrease in the coming weeks and months and we will have to prepare ourselves for this new world that you
46:25will be working in a world that will require the types of disposables that we didn't use more regularly before.
46:32And that will allow us to rely on virtualization and patient data.
46:36To do more with these patients than we ever did before,
46:40and then just very quickly,
46:42there are a couple of questions it came through.
46:45So someone asked to talk about device shortages and then supply for hospital level equipment not expected to rise.
46:52So let me add about the first one yet so we are there will be shortages for the next,
46:59probably several weeks, months or more as the global manufacturing footprint is almost exclusively focused on delivering vents for hospitalized patients.
47:06Again, both noninvasive and invasive.
47:08But what I've heard as early as late as this morning when I was on a call with some folks in Europe.
47:16They are modeling that the drop off in demand prevents will be pretty sudden happened within weeks or a month.
47:22I think to answer the second question,
47:24what I have seen from my perspective is that this is obviously a pandemic of hot spots.
47:30The virus doesn't understand Geo political boundaries.
47:32The virus just understands there are a lot of humans and they are allowing me to move between them because they are spreading droplets and touching each other.
47:41And so when you look at northern Italy it looks very different than the rest of Italy.
47:46When you look at the New York City Metropolitan area.
47:50It looks very different than other parts of the United States and what we've seen is there was a frenzy of acquisition of Ventilators,
47:59and we have probably preloaded the system with enough devices or hospitals in most cases.
48:05Again, hotspots excluded where any second or subsequent waves will not create another spike in demand.
48:11There may be small regional or localized spikes in demand as a place like Mexico or Brazil may or may not blow up.
48:20But we have an opportunity for some of the places that overstocked to actually send ventilators to areas that need them.
48:27We are seeing FEMA in the US already talk about sending some of the 100,000 plus ventilators that they've ordered to other countries.
48:35We know the World Health Organization is working on getting devices to other countries,
48:39and we even saw here in the US,
48:42California bought too many ventilators and sent something to New York.
48:45So I believe within the next few weeks we will start to see the supply of devices start to equalize.
48:52I think one or two more questions may have just come through.
48:57Uh, is the
48:59supply. HST
49:03being delivered to avoid patient contact.
49:07Um DMV orders
49:08and 90% of requirements
49:10will be accepted as, so we don't answer the last question first was around some of the reimbursement policy.
49:17I don't know if we have final answers yet,
49:20but I believe that there are a lot of different stakeholders that patient groups,
49:25provider groups, even some of the industry groups trying to work with government entities and the payment and policy folks to understand which policies make sense to persist going forward.
49:36I think there's probably consensus that greater.
49:38Allowance for telemedicine. Telehealth Telemonitoring,
49:40remote patient engagement. Those are the types of reimbursement policies that probably should persist whether or not we're going to change payment or reimbursement policy around in lab tests.
49:51Home sleep testing versus no testing.
49:53I think it's way too early to tell if that if that policy is going to change,
49:59and then sorry the other question was prepared for resurgence in September or October.
50:05I think if we were reading the tea leaves correctly.
50:08As I said, the systems have been preloaded with a lot of in hospital capable ventilators and so to prepare for any second or subsequent waves is really going to
50:19be around personnel facility pee pee in procedures by then.
50:23Hopefully the supply chain issues will have been hammered out and manufacturers will have returned to the normal mix where they're probably still making more ventilators than normal.
50:32But back up to speed with the numbers of pap devices,
50:36disposables and other supplies that they were able to make.
50:40So hopefully that answers most of those questions and I'm happy to stay on and continue with the discussion.
50:48Thank you
50:49so. I have a
50:51question. Check first it is doctor white here from restaurants or.
50:57I'm here, would you like to say something first?
51:02Share questions,
51:04yeah? Very brief afternoon afternoon as it was interesting on the around the 1st of March.
51:10I contacted a colleague of mine in North northern Italy asking how things were going again.
51:15Stefano Nabhani Rollback an amazing email it goes.
51:17This is David. It is apocalypse now.
51:20Words cannot describe what's happening here and he sent me a few pictures.
51:24He said we don't have enough pap machines which is flying by the seat of our pants and it was a very daunting sort of moment.
51:32So we have in Phillips we said Gosh what can we do?
51:36And we very quickly flipped over RC Pap Machines intimate making a Bipap St device that could be a ventilator on the lies,
51:43with doctors saying we need.
51:44We got to where we could crank out 5000 ventilators a day.
51:48It was a low end ventilator.
51:50I'll tell you about it when they could do 5000 today.
51:53But to do that we had to shut down,
51:55see production completely. Standard C pap devices for a short period of time that can switch back and forth on very quickly.
52:01and I agree with documented that this demand from inhalation just gone way down.
52:05I mean, it's just. It's nothing like it was.
52:08A month ago, so I think everybody can get back to where we're producing reasonable numbers of C.
52:13Pap device is obviously demand for cpac device is going down is the lab so inactive.
52:17S at the DMV's the only other point I want to make is I think I think we're going to
52:23have enough. Supplies and
52:25accessories to for you guys to practice careful,
52:28Medison Mania. Need non vented masks,
52:30you need exhalation ports. You need filters.
52:32Insert for that and I think it for in lab situation to be doing a see pap titration with a vented mask and what not is not very wise.
52:42Even if you don't know if the patient has covert at this particular time you only use the reasonable care.
52:48Make sure that air is filtered on the exhalation side,
52:52obviously with the filter and we think you're going to be able to have.
52:56Those resources, the last comment I'll make is that I was really a lot of capability in terms of managing apnea patients.
53:04Remotely, once you get on my C pap device,
53:06you can look at every breath they take is Robert Thomas was talking to us about.
53:11You can see exactly what's going on.
53:12Auto titrations not meeting your needs.
53:14You can adjust the pressures as necessary,
53:16but not getting him on the initial pap device may be harder and you have to use home home testing and things like that.
53:22But once you get him out there is a lot of information available.
53:26I think to try to help you manage those patients.
53:28So I'll stop there, such as you can ask
53:31questions. Doctor krieger, I think you had a question.
53:35Yeah, uh, so this is for David and Carlos.
53:39So one of our challenges is to have a diagnosis and you think your companies can make a pack device that can actually create a split night study where for
53:51two hours or three hours whatever,
53:54there's the minimum amount of pressure which would be about four San San meters of water pressure and then.
54:02Actually do a titration. Bye bye.
54:05Going into an auto mode.
54:09I'll call me first. You could certainly do that
54:12there. I think that part of the problem is it 4 centimeters of water pressure will treat a moderate amount of atoms.
54:19May be hard to get a handle on exactly what the initial severity was with four centimeters or water pressure.
54:25Obviously getting an auto titration thereafter is a fairly straightforward operations.
54:29Devices can certainly do that.
54:30Why would you want to do that though,
54:33instead of just doing a home test and then went straight to attach to an auto tax rating device
54:39mayor? Well, yeah, I is it.
54:41I think it's a
54:42matter of logistics. An overall costs.
54:45I think at the end of the day work pretty good.
54:48I think at predicting which patients are are going to be a problem.
54:53I mean right now there have been several patients where I've actually prescribed cpac with no test at all.
55:00Just, you know, an I'm keeping my fingers crossed that the insurance companies are going to pay for this,
55:06and so far I haven't had any blowback.
55:09But I think to have an apnea index,
55:13even if it's at a,
55:15you know, sort of a lowish pap pressure would be way better than than
55:21nothing. You suggesting you only have one visit to the home to as opposed to getting the getting the HST device there and then get it back to you and
55:31then? Actually having to get the see pap out there.
55:34Yeah, that might. I don't think that would be actually very hard to do,
55:38but it's not something I
55:39think we thought about a lot.
55:41Yeah, just to echo, it's not difficult to do.
55:43It would be simple to do I think what what you know.
55:46As any company, I can't speak for the commercial sign,
55:49but as any company they would want to know that there's a market for it and maybe in the in the world going forward.
55:55As I mentioned, as as care moves closer and closer to the patient and we can virtualize things like diagnostics and titration more effectively.
56:01There may be a market for that so.
56:04Good question.
56:08So please everybody if
56:10you have messages you can send in a chat um address to to everyone and we can start reading mof.
56:19One question I do see right now is our providers billing for remote patient monitoring for managing patients with sleep apnea.
56:28Designing. My panelists want to.
56:31Training on that. So my understanding about
56:35I haven't used it is
56:38that one person of month can bill.
56:42For that I believe they have to spend.
56:46I think it might be 30 minutes to bill,
56:51so it's and if someone from like diabetes bills for remote patient monitoring than than you can't as asleep provider.
57:02I think it is potentially something if if we are doing more sort of full reviews of.
57:09You know the actual waveform data and using it it sort of in lieu of sleep studies.
57:15There may be something to look into there.
57:22I have another question, why
57:24is it AM are the only one with a disposable home sleep study device?
57:30I have
57:31a an answer to that one.
57:35Yeah, so I've seen another device that is available in other parts of the world and is trying to get FDA approval.
57:44Currently that is a disposable wearable device,
57:47uses a similar approach as the peripheral arterial tonometry that the watch pad device uses in combination with other channels,
57:56it's. I don't remember the name of the company,
57:58but it's, uh. It's it's being used in other parts of the world I've I've seen it used in Asia and actually tried it one night myself.
58:05I'll also comment that we acquired a company about a year ago that has a disposable,
58:10basically six sticks on the floor and has little can I go into the nose to get nasal pressure?
58:15You can get effort from venous pulsations.
58:17You get spo two reflectance and you can get ahead position and so it won't be available.
58:22Probably for most of it another year unfortunately.
58:24But there are others coming out so that I think that would need to be pretty common commodity.
58:30And someone just said in the chat it is the night owl.
58:34It's made by a company.
58:36It just reminded me. Echo sense night owl,
58:39small fingertip. The device that does spo two derives P-80 and then has a 3 axis accelerometer.
58:46And this is in dear,
58:48I just want to jump in.
58:50Mayor said earlier identifying the bread and butter,
58:53obstructive sleep apnea patient and starting empiric C pap.
58:56I think that something that we could do.
58:58The question becomes, what do we do with these more complex patients that have been waiting in the wings for labs to reopen?
59:06And you know, there are the obesity hyperventilate yrs.
59:08They're the ones with BMI is of 50 and 60 and you have no idea what their pressure requirements are going to be or their oximetry requirements.
59:17An while we're waiting like what's the best way to offer some sort of therapy.
59:22Ann, is there a way to integrate diagnostics and therapeutics into one unit with these disposable elements?
59:29and I know the res Med,
59:31and I believe restaurants as well.
59:33Has these have these modular units that can accommodate you,
59:37know, unintended testing? The question is,
59:40can that be expanded to include CO2 monitoring an and also allow that disposable capability?
59:48That's going
59:49to be hard to do all of that.
59:52I mean, none of these devices,
59:53obviously themselves are disposable, and CO2 testing is to get an entire was certainly affected.
59:58Separate separate devices. For us,
59:59you have to put that in the home and believe in the home indefinitely and whatnot.
01:00:05That would be an or you getting,
01:00:07you know, realistic numbers from Intel that transcutaneous or entitle and whatnot so itself.
01:00:12That you know if this thing persists,
01:00:13I think we're going to have to think hard about some of that stuff and try to get to where we can do more and more and more than Home
01:00:19Buttom. Right now I think what you're describing,
01:00:22at least in a hypo ventilating that you're trying to attach rate.
01:00:26You might even if that's if that's the end point,
01:00:29you might even be better using a vaps truck type device you know,
01:00:33pick your title volumes and everything based on ideal body weights and whatnot,
01:00:37rather than trying to do SEO Twos,
01:00:39and you're likely to get closer
01:00:41than
01:00:41you are just guessing otherwise,
01:00:43yeah. Read it. Symmetry.
01:00:47Knock, knock.
01:00:49Mission. Basically,
01:00:51for Wolf, can I jump in for one quick second?
01:00:56Just wanted to support what doctor White was saying an emphasize the new guidelines from the ATF on obesity hypoventilation that emphasize the fact that an Ivy should be started
01:01:08initially and that after three months of therapy on an Ivy,
01:01:12is the right time to look and see in the lab.
01:01:16If we can take a step back to C Pap and those initial N Ivy settings are most easily done with that therapy.
01:01:26Shooting for
01:01:27both prolonged inspiratory time so that we can do good lung volume recruitment
01:01:32and looking at shooting for eight PCs,
01:01:35Portillo ideal body weight and that can be done on a variety of devices right now,
01:01:42but if you haven't, I'd recommend pulling that relatively new ATF guidelines 'cause it does go through all
01:01:50of that. Thanks
01:01:54Lisa. Lisa,
01:01:55can you find that guideline and put it into the chat of this if you can?
01:02:03Yeah,
01:02:03sure, no problem. I'll just
01:02:05take a minute, yeah? What one comment from one person was issues related to staff being worried about having face to face contact and especially if they are older age
01:02:18or have underlying medical conditions.
01:02:21And so you know one comment is that might affect some more experienced staff members.
01:02:28So whether anyone has any comments or experiences with that?
01:02:39Yeah,
01:02:39we would
01:02:40encourage that employers have a policy of encouraging sick employees to stay at home and also providing accommodations for those who need them.
01:02:52There were, you know,
01:02:54we had OSHA and
01:02:56workers comp and workplace accommodation rules prior to the pandemic,
01:03:01and I think that, uh.
01:03:05In many places those have been bent in order to accommodate overwhelming demand.
01:03:09Uhm, but on some level I think employers need to be looking at what's happening with their workforce and who needs to have an exemption versus who doesn't and what
01:03:20sort of accommodations would be appropriate.
01:03:25So the traditional sleep lab has.
01:03:28Pretty much use the. Next bed,
01:03:31next deck, next patient approach.
01:03:33We may have to. Streamline a bit more better match.
01:03:38The technician that type of study with the patient.
01:03:43And, uh. You know if the virus hangs around,
01:03:48it is inevitable that. By coincidence or otherwise,
01:03:51that a patient will come to the sleep lab and.
01:03:55You know, a few days later will have colored.
01:03:59And then, uh, only a weidel genetic analysis will tell us Whether.
01:04:05You know where they got it from?
01:04:07Was it community was in the lab?
01:04:08The whole thing is going to get kind of messy.
01:04:12But that's something we have to be ready for.
01:04:16And, uh. Uh, what we do out here in Boston is for the most complicated patience.
01:04:22Uh, we have a physician guiding the titration,
01:04:25then it doesn't really matter who exactly the technician is.
01:04:28You can have the youngest technicians as long as they can put the leads on.
01:04:34You can still guide them through.
01:04:36I will let it figure out ways to keep it safe and keep it good.
01:04:43Is
01:04:44there any comments from our ASM folks about where they see recommendations going up?
01:04:50Especially really just sort of watch doctor Thomas talked about in terms of trying to use some of these non study ways to manage patients.
01:05:01Is that something you think ASM might look?
01:05:04Try to put out guidelines related to.
01:05:08So this is Shannon. So first
01:05:11of all, I think you to doctor Thomas for that overview,
01:05:16which was concise and really shows how well positioned the sleep field can be compared to other fields of Medicine for being able to roll out really advanced.
01:05:29Mechanisms for a remote monitoring of patients and diagnostics of patients.
01:05:34So I think that sleep may be better positioned than some other fields,
01:05:40and I. I can't speak on behalf of the Academy,
01:05:44but I certainly think that there's a lot of will to be able to deliver the best possible care for our patients in the safest possible way.
01:05:55There was an interesting Lee,
01:05:56and again, I'm just a point.
01:05:59Others on the call to our reference health policy update that was sponsored by the Academy yesterday that reviewed a lot of not just some of the changes from CMS
01:06:10and other federal programs. But also some of the things that we might be able to incorporate into our practice longer term.
01:06:19So earlier someone had a question about remote patient monitoring and those codes for for billing,
01:06:25for example, are included on that webinars,
01:06:27so I would certainly certainly point you to the direction of the ASM website to be able to review some of those things.
01:06:37Yeah, so um, one of the other things going forward is going to be weather.
01:06:44Once this is all over.
01:06:46Whether CMS what they're going to do with the waivers that are that are available right now to us because some of the some of the hoops that CMS mandated
01:07:00which most insurance companies have picked up in my opinion,
01:07:04were insane increase costs. An actually chased.
01:07:08Young Fellows away from the sleep field.
01:07:11In other words, we were seeing patients,
01:07:14you know, for the 31 to 90 day followup,
01:07:18an most of those were,
01:07:20like, frankly, boring patients didn't like it.
01:07:23Doctors didn't like it and and it was really,
01:07:27really getting to. Everybody's as sort of anxiety and and I think the insurance industry in CMS needs to recognize that some of the.
01:07:38Some of the the waivers that that are in place right now are actually pretty good.
01:07:44In In other words, we don't need to go back to the way the way the way things were,
01:07:50and I don't know whether The Academy Is going to lobby them to let them know that.
01:07:55Things really are better now in terms of managing some of the patients video calls for example,
01:08:03or fabulous. Most patients really like them.
01:08:08Right, I think that if there can be a silver lining to the situation,
01:08:13it's learning how to provide more effective care on all fronts.
01:08:17Cost effective, more patient centered care.
01:08:19I mean, we can learn from those things,
01:08:22and I think there is at least some will to be able to retain those things that have made a positive difference in our practice.
01:08:31and I hope the Academy will advocate in that direction as well.
01:08:39So some other questions that I see here as anyone converted their sleep testing rooms to negative pressure rooms or gotten quote sort logistics and cost.
01:08:48I'm not sure that any of our panelists have,
01:08:51but any comments there. Um?
01:08:58And can you speak to mitigation risk strategies for text when adjusting face mask for leaks during a titration study?
01:09:08Most
01:09:08most places are not doing titration studies.
01:09:11At least we're not is.
01:09:13I don't know if anybody else is right now.
01:09:19We also are not at Penn.
01:09:22I think that, uhm. The one place you can look to for guidance is certainly the CDC website and also what's being done in hospitals with respiratory therapists or having
01:09:34to go in and work with some of these patients.
01:09:38That's our best available guidance right now and a lot of sleep labs are actually not equipped to provide negative pressure because their windowless rooms.
01:09:47There's really no outlet to let the pressure out.
01:09:53In the real problem is we don't know whether these patients are coded positive or not,
01:09:57and really the only way you could do that in that circumstance,
01:10:00'cause you're obviously going if you're adjusting their master going to get exposed to the exhaled air.
01:10:05Only thing you can possibly do is wear PE and how much PP you wear in that situation would have to be decided on by the lab.
01:10:12I. I'm glad too, depending on your practice situation,
01:10:17it might be a good time to get in contact with your colleagues.
01:10:22An ambulatory surgery centers. They're dealing with many of the same issues their patients are coming in from the community,
01:10:30and they will be undergoing airway procedures,
01:10:32outpatient airway procedures as well,
01:10:34and so at least in Northern California.
01:10:37I feel that the movement forward on how to deal with testing,
01:10:41for example, and symptoms screening is.
01:10:44Also happening in those venues,
01:10:46and it's useful to be able to sort of cross pollinate.
01:10:51Yeah, I think that an understanding this covert status of individual patients is going to be really important,
01:10:57so we've had you know,
01:10:59up front screening for symptoms and temperature checks,
01:11:01but now we also have the status of testing results and whether the tests were negative or not,
01:11:08the person have a known exposure,
01:11:10not do they have symptoms or not.
01:11:12So I think that the first thing to do before even talking about reopening a lab and having a tech come in contact with the patient is understanding What is
01:11:22this status. The testing status of the patient and of the end of the technologist with the understanding that you know what Karen said earlier that patients are most likely
01:11:32to shed virus in the one to three days before they develop symptoms and so it's a big challenge that you know,
01:11:39we don't want and we certainly don't want the same.
01:11:43Tech then going into multiple rooms.
01:11:44So there are lot of safeguards that would need to be put in place you offer one to one.
01:11:51Text patient do you leave downtime between studies?
01:11:54The room has a chance to just sit for 72 hours the way that home studies are being done.
01:12:01Right now there are a lot of logistics to consider before resumption of services.
01:12:07Yes, so clearly the background prevalence in that community and.
01:12:12Yeah.
01:12:15One
01:12:15of our missions is to improve the sleep of of society and one and I've been asked to give lectures to groups because insomnia,
01:12:25weird dreams, post traumatic stress.
01:12:27Nightmares are really common up there right now,
01:12:30and I suspect that in the next few years we're going to be seeing a lot of chronic sleep issues related to what is going on right now.
01:12:41And that's something that we as a field are going to have to.
01:12:46Deal with and we're still gonna have to deal with patients with Narc with narcolepsy.
01:12:52I had, you know we actually are continuing to to do PS GS and MSL teasing patients like that and we had one yesterday.
01:13:01In other words, we've been focusing on on sleep apnea,
01:13:04sleep breathing disorders, but the reality is,
01:13:07there's a. There's a much bigger mission that we in the sleep community actually haven't.
01:13:13We must
01:13:14not forget that.
01:13:15I agree with that mirror an we also we have technologies available that were not embraced before because the reimbursement protocols made them unviable's with things like Actigraphy,
01:13:26an even PV TS which are available through mobile apps and on websites.
01:13:30If some of those could be brought into production into practice that we have objective data when we assess our patients that avoids reliance on laboratories.
01:13:40I think that we need to really think outside the box in terms of patient assessments.
01:13:48In one uh, next question,
01:13:50uh, we didn't touch on home sleep studies um earlier,
01:13:55for the sake of time,
01:13:57but obviously that's a big issue.
01:13:59and I know in our lab we're mailing out,
01:14:03we don't have the disposable studies.
01:14:06We're mailing out ours with a 72 hour wait,
01:14:10which basically makes it take about 2 weeks for one study to get one.
01:14:16You know, one test per per device.
01:14:19So that that you know if we are ramping up those studies because that's what we can do I think we we definitely start hitting supply side issues.
01:14:28Based on that, I know we asked to buy some more devices and then there were none to be had.
01:14:35So if there's any comments on what to do with the homes and and as we potentially see more patients for quite a while using home studies,
01:14:44how to meet that demand?
01:14:46Doctor Johnson this is Irene from somewhere.
01:14:52I hello so I wanted to talk about um,
01:14:56since we're on the home seat testing at somewhere.
01:15:01I'm not sure everybody knows,
01:15:03but we are a middleware platform and we integrate with home.
01:15:09See tests we integrated with Airview an encore anywhere.
01:15:14So what we have. Seen from our somewhere users is that one of the things that they do is they use watch pads.
01:15:25The watch pad device and because we have an integration with them are as well from a workflow standpoint,
01:15:35this model actually works, so when you register a patient in your AMR it comes into somewhere and then we push the demographics to the device itself at that point.
01:15:50Um, in this model, UM,
01:15:53one of our health system.
01:15:56What they do now is that Itamar will actually Itamar will actually take care of the shipping,
01:16:06and they would ship the devices.
01:16:10We have the sleep centers and then at that point once the device comes back to,
01:16:17you know their their clinic and this is again from Itamar.
01:16:21This is just what we do with for a health system.
01:16:26Once the study is back then it goes into the physicians Q to review the tests,
01:16:33finalize the study annuar, move on to the next patient,
01:16:37right? So that's for the watch pads.
01:16:40Devices now we're about to integrate with the watch pad one direct.
01:16:46I'm sorry the watch Patton one and so the integration is going to be again from the EMR to somewhere,
01:16:55somewhere, will or E tomorrow.
01:16:57Will ship advice on behalf of the sleep center,
01:17:01then it goes into the physicians inbox.
01:17:05Once a study as collected.
01:17:07So we've seen that we've seen other health system that are.
01:17:12The same following the same model and for non disposable disposable devices such as the Knox or the Alice Night 1 device.
01:17:24If the sleep center have the devices or the inventory again,
01:17:30there's no patient contact. You will use the shipping module within the platform.
01:17:37Send it out with video or do a telemedicine or Telehealth.
01:17:43Just to make sure that the patient is actually using it or or educate them.
01:17:50Then once the devices back they ship it back and at that point it goes to the position for a review.
01:18:00So that's what we've been doing from from somewhere and a lot of our customers are.
01:18:09Are following this model today and at the same time.
01:18:12Once you know they died once,
01:18:14if the patient is positive auto pap,
01:18:17you know the order for auto pad and because we have an integration with both,
01:18:23you'll be able to see not only the diagnostic study,
01:18:26but you'll be able to see their compliance in somewhere.
01:18:32Thank you in any any of our other panelists with comments about the home sleep studies.
01:18:39No,
01:18:40there there was a really good question about risk of infection to bed partners,
01:18:46which is a higher up and and what what?
01:18:50Our recommendations and I've had some patients like this an basically if the patient has a mild to moderate OSA and has Cove is coughing a little bit of Wheezing,
01:19:04maybe headache, fever, but. Other than that,
01:19:07there OK? Let's say they haven't hi less than than 15 or 10.
01:19:12I tell them not to use the C Pap unless there's something to get rid of the viruses.
01:19:21And so that may be the best approach.
01:19:24And if the patients are a little bit more severe and Robert,
01:19:29Thomas and I had talked about,
01:19:31this is maybe those patients that they become a little bit oxic.
01:19:36You might be able to order oxygen for them,
01:19:40because what we really don't know in the home setting,
01:19:44how dangerous the current C Pap Circuit start to bed partners and other people in the home.
01:19:51Really sick they should be going to hospital.
01:19:55Yeah,
01:19:55that's exactly what we recommended.
01:19:57Mirror in the ASM statement,
01:19:58which was basically a risk benefit analysis to look at.
01:20:02What is the risk of transmission to others in the household?
01:20:05Is the patient able to self isolate and or they living in close quarters in a multi unit dwelling with a lot of vulnerable people nearby and so forth and
01:20:16then the other piece of it is how danger is it for the dangerous?
01:20:20Is it for them to stop the see pap therapy?
01:20:24So if it's? You know somebody with a lethal arrhythmia,
01:20:27or, uhm, you know an older person at risk of falling down and hurting themselves.
01:20:31If they miss a few nights of their C Pap and so forth,
01:20:35and that those decisions are best made on an individual case by case basis rather than a blanket policy.
01:20:41But the physician be involved in that,
01:20:43that type of decision making.
01:20:46So the really severe ones with profound hypoxia who need to have some kind of treatment,
01:20:51if they can save, isolate,
01:20:52and find a way to continue their treatment,
01:20:55that would be great. And then the milder ones who have to stop for awhile if they get very symptomatic,
01:21:01then consider other options prevent therapy,
01:21:03position treatment and so forth.
01:21:07So I have not had any patient need it yet,
01:21:10but if anyone son event later.
01:21:13And I love so covered.
01:21:14I think that person should be admitted because you just can't take a risk.
01:21:19Yeah, so um, we had a,
01:21:22uh, a patient with obesity hypoventilation syndrome,
01:21:25who had very severe kovid,
01:21:28was in the hospital, and after about 1314 days he was on.
01:21:33He was being ventilated and after about 13 or 414 days when things look like they got better,
01:21:42he was excavated and then he stopped breathing.
01:21:45An basically died. And so you know,
01:21:48people who are. Immensely obese.
01:21:51Uhm, you know, excavating them is a huge big deal.
01:21:55And it's, you know their Airways at risk.
01:21:58It's all in the flame you pulled out the ET tube and they are in really bad clinical situation at that point.
01:22:07And maybe they should instantly be started on an Ivy that I'm not sure
01:22:13of yet.
01:22:17I see a another question about um homesick testing specifically with pediatric population anymore comments about whether it's time specially for older kids to start doing home sleep studies on
01:22:31any of them. So
01:22:38coming from a person who does not do pediatric sleep medicines basically.
01:22:44Oh, I think it's just a.
01:22:46It's time that it ever since.
01:22:50Do home sleep testing. It clearly will be kid,
01:22:52so are not appropriate. But uh,
01:22:55the technologies become good enough to at least rule in.
01:22:58You may not be able to rule out as well that I accept that.
01:23:03Clearly you can rule in someone who has substantial sleep disordered breathing.
01:23:08After the first few years of life,
01:23:11as long as. Be smaller and more compact devices.
01:23:15Stick onto you and give you the data you want.
01:23:20I think it's just the formula recommendations that PS is the gold standard and it should be gold all the time.
01:23:27I think it's, uh, interfering with the forward movement of the pediatric sleep areas.
01:23:33That's my personal opinion, but like I said I do not practice pediatric,
01:23:37which
01:23:38I agree with that and I will also chime in as somebody who doesn't practice Pediatrics.
01:23:43That one of the things we may need to be looking at is what should the diagnostic criteria before qualifying an event as a hypothenar napping on?
01:23:52Do we still stick with the Medicare rule of 4%
01:23:56and should that apply to young children who may not have those BMI's and whose events may be more related to tonsillar hypertrophy?
01:24:03Recognizing there's a higher prevalence of obesity and so forth,
01:24:07but our 2% in 3%
01:24:08and 1% events still significant and contributing to daytime functioning.
01:24:11So I think we need to move away from the formulaic approach and be much more patient centered when we
01:24:18when we move
01:24:19in that direction. I just
01:24:22wanted to add a someone who does practice in Pediatrics that I agree in particular with those comments,
01:24:28but also what doctor kind of Harry mentioned earlier,
01:24:32which is, you know, Pediatrics is zero to 18 and and not every pediatric patient is the same and there can be a lot of complex clinical complexity with some
01:24:43patients, but I think that in particular looking at the adolescent age group and understanding what the role of home testing could be,
01:24:51especially in consideration of. Sleep patterns of adolescents and things like that that this could be a great place to start I also agree with doctor Thomas.
01:25:00You may not be able to rule out an ever melody,
01:25:03but you certainly can start to use home testing to rule in or understand more about sleep in that population.
01:25:11I'm almost concerned that we're gonna start doing this and then the insurers aren't going to pay for it.
01:25:17Um, in Pediatrics. I mean,
01:25:19we all know how perverse they are.
01:25:21Maybe I'm wrong about this,
01:25:22but Our wear off and doing things like repeats,
01:25:26sleep studies to re up children see Pap prescriptions if their adherence isn't perfect,
01:25:31which is really the cost benefit of that is so low we know they have established sleep apnea we.
01:25:38I'm always leery of using adult criterion kids because we run into this.
01:25:43For example all the time with adherence data.
01:25:46You're taking a child with Down syndrome and expecting them to be as inherent in the first couple of months.
01:25:53As like a 60 year old engineer and the home care company will take away the machine.
01:26:00Uh, if they can't hit those criteria,
01:26:03I worry with ages T we're going to get some pushback,
01:26:07weirdly enough. Yes,
01:26:11someone who takes care of those Down syndrome patients once they age out and reached the adult population.
01:26:18I completely agree with you and we need some some real help with paper guidelines.
01:26:24Glass half
01:26:24full though at times like these require creativity to be able to take care of our patients.
01:26:31and I think we can as a field show that we can provide value to patients and a wider variety of settings and I think it's on us as.
01:26:42As the sleep experts to be able to do that.
01:26:45Yeah, I agree with that.
01:26:47I mean, we need to advocate for our patients in the way these policies are created.
01:26:51And that's that's what the ASM is trying to do during the pandemic as well.
01:26:58And
01:26:58I see some questions about cobra testing prior to sleep studies with comments of doing it two days before,
01:27:07four days before needing rapid testing.
01:27:09You know, I think there from my standpoint when I've heard in my institution is the debate of if you get it early enough,
01:27:19do you get a chance to test another person and actually fill the bad versus if you wait till last minute?
01:27:28So appreciate anyone else's comment about what would their ideal be.
01:27:33Or what are they doing as related to testing?
01:27:41My personal choice is that it gets done a rapid test before the sleep study.
01:27:46Sure, some some we will lose a few studies because.
01:27:50Is, uh. Surprise positive. But if it's you know how many days before can you do?
01:27:57Just think of the burden to the.
01:28:00To the patient, where would they test it?
01:28:03Peace PS office. Now if there is not if when there is ultimately do-it-yourself home test,
01:28:10which is accurate, that would be the solution.
01:28:14But we are going to be in this intermediate grey zone where that is not going to be available and.
01:28:19We have to make some decision as to how inconvenient the whole process will be.
01:28:25For the moment, I'm thinking that it gets done.
01:28:29When they come in, and perhaps if it's a diagnostic study,
01:28:33it can continue. One
01:28:35other issue I think would testing is is how is you know?
01:28:39Is it completely paid for by insurance?
01:28:42Is it rolled into the sleep study payment you know?
01:28:45Is there any issues related to that?
01:28:47Are people going to get a bill for $500 or something?
01:28:51You know something? Just for that that test night I I don't know
01:28:55if it's a role in that would be really really hard
01:28:58to do. Yeah, I I mean so.
01:29:00A lot of what we're discussing now is is sort of.
01:29:04The failure of American Medison,
01:29:07just like there was a failure to deal with this pandemic and see Ms has been has been telling doctors how to practice and how to build an doctors have
01:29:21sort of lost the. You know they're not controlling Medison anymore.
01:29:28CMS is defining diseases. It's defining what tests you can.
01:29:32You can do. This is this is a.
01:29:35This is a really big problem in the US and maybe one of the outcomes of all of this is going to be you-know-what.
01:29:44Maybe we should trust our doctors.
01:29:46Maybe we should trust them in terms of running things.
01:29:50I actually had a long discussion about this about a year ago with our representative in Congress about this issue,
01:29:58where where. Congress, you know,
01:30:00runs CNS and a lot of the rules about diagnosis and treatment.
01:30:05They call the shots for the whole country an that I think in the long run is not gonna be a good thing.
01:30:15If I can just chime in real quick,
01:30:18I think this is a really interesting discussion around how we can take control of the field of the industry in a way that's meaningful and just to Harken back
01:30:29to the comments I made earlier that the world has changed and which of those changes can persist.
01:30:35This is a really good time's like Doctor Krieger was saying to think about.
01:30:40First and foremost what is best for the patient.
01:30:43And then Secondly, what's best for our health system.
01:30:46For its viability today and for its long-term viability,
01:30:49I have the privilege of not just managing the medical affairs function at res Med,
01:30:54but also managing our government affairs,
01:30:56and I've had the pleasure of working with a lot of the folks on this call.
01:31:02I heard Lisa Wolf earlier,
01:31:03for example, chime in on some of these payment policy and reimbursement issues that just don't make sense.
01:31:09And maybe, after all of this,
01:31:11There's an opportunity for everyone from patient to provider to industry to come together and help.
01:31:17Make the changes that are that makes sense.
01:31:19Stick those that don't revisit them and start to craft a healthcare system that works for the good of the patients in ways that hasn't before.
01:31:28This. Maybe this is an opportunity to sort of reset the playing field a bit.
01:31:37I agree with that. I think that's a great point,
01:31:40and one of the other things is pandemic has done is really bring to the surface all the different ways our health care system hasn't worked,
01:31:48including all the disparities on the rates at with patients are dying who are from marginalized groups lower socioeconomic strata.
01:31:54We really do need to create a system that benefits you know,
01:31:58the greatest good for the greatest number,
01:32:00which is what this pandemic has,
01:32:02has brought to light.
01:32:07I see a question. Here.
01:32:09Is any sleep labs in Massachusetts currently doing in lab testing?
01:32:14We're not open for in lab testing right now,
01:32:17although working on are planning to try to be ready.
01:32:21Once Massachusetts as sort of ready for that,
01:32:24but I've heard of some private places in Connecticut over our border.
01:32:28Do you know of any
01:32:30doctor Thomas? No, just home testing.
01:32:33I know that if anyone doing leftists,
01:32:35so in so at Yale were still doing in lab testing,
01:32:39but we're fairly careful about who we do it on.
01:32:43And so. When, when, when a patient's name comes on,
01:32:47we will frequently look at the referral in a lot of detail and sometimes will call up the patient than,
01:32:55say, look, do you really want to come in for a sleep test right now,
01:33:00or would you rather wait an most patients would rather wait,
01:33:04they don't want
01:33:05to come in right now,
01:33:07so. The end of the day.
01:33:09It's the patient who's going to decide.
01:33:12That's what we're
01:33:13doing here. I don't know what's happening in other parts of the state.
01:33:19And I see a number of comments about Um PPD choice.
01:33:25Um Kaya, 90 fives and just messing gloves.
01:33:28Uhm? And whether or not to use gowns,
01:33:32any any comments on on PPY?
01:33:36I think you're dealing with a titration,
01:33:40and 95 is probably wise.
01:33:45But for a diagnostic, perhaps just ask gloves.
01:33:52It's more gut. I don't have data obviously.
01:33:55Yes, and we were with the Academy.
01:33:57We were pretty conservative with our recommendations as well that.
01:34:02Because with C Pap, it's not just whether there's appreciable leak.
01:34:07It's that we accept 2240 liters per minute of air as OK,
01:34:11and so there's definitely if that patient is presymptomatic and has the potential for transmission,
01:34:18then we're looking at probably viral dispersion distances that exceed the six foot limit and then having to get in there and actually adjust the mass can be really in
01:34:30close proximity with the patient.
01:34:33I think is a. Uhm,
01:34:35you know it's it's a dangerous proposition.
01:34:38And so if the studies apps.
01:34:39This is why we advocated for lab closure for Pap Titration Studies.
01:34:43And if their resume than they need to be done with a lot of caution and absolutely with I mean it would be great if negative pressure rooms were available.
01:34:54Along with the a 95 masks and with face Shields and gallons in the full,
01:35:00but unfortunately we're in an environment where that's not uniformly available.
01:35:05And what if we do have negative testing?
01:35:09Negative pressure rooms. Now if you have a negative viral test done that day or the negative,
01:35:15this data that
01:35:16you hold it right so that in the clinical environment you can have a negative test.
01:35:22That's a false negative, and those rates can be anywhere from 20 to 33%.
01:35:28Um? So a single negative test is probably not sufficient to rule it out,
01:35:34especially if the person has other risk factors.
01:35:36If there's symptomatic. If they had a known contact,
01:35:39and so at least two negative tests in a row,
01:35:43and I believe the CDC says at least 24 hours apart along with an absence of symptoms,
01:35:49certainly being afebrile and not reporting known Contacts,
01:35:52and they're not in quarantine,
01:35:53etc. Although
01:35:55I would say that you know that's in general for the hospitalise patients,
01:35:59so if you have a person at home who you ask,
01:36:03have you had any fever?
01:36:05Have you had any symptoms you know?
01:36:07Do you know anyone around you?
01:36:09You know that is particularly sick and they answered no to all those screening questions and then you have a negative test,
01:36:17and when they show up at your door,
01:36:20your checking for fever one more time?
01:36:22You know in that population that should be.
01:36:25Low risk, you know what?
01:36:27What can you do? and I think some of the answer goes back to what is the community transmission rate.
01:36:34You know? I think we're finding out of the we're now testing every single case that comes into the hospital for Covad and finding about 5%
01:36:43being positive, even if they're coming in for things like and a sithis or something totally random.
01:36:49So I think some of it does depend on what is the rates out in the community.
01:36:55That might sway that pretest probability,
01:36:58and so it is there you know.
01:37:00Is there a level at which we do sort of trust those results and do it,
01:37:07you know? I'd say is,
01:37:09you know, in our hospital right now,
01:37:11if there's a patient that is on Bipap in RC Pap at home and they come into the hospital for something else.
01:37:20And again their code but negative.
01:37:23They aren't put in a special precaution room,
01:37:26so I imagine given our infectious disease,
01:37:29who is usually very conservative about about things given they don't feel that those people need to be in a special situation or with special.
01:37:39Precautions that they will simply tell us that we can't use the full error civilization precautions if we have the testing in place that's negative.
01:37:51I
01:37:52think we will have to see what the EMT folks do.
01:37:55I'm sure they're putting a Heckler thought into this.
01:38:00It probably will be coming up with guidelines soon,
01:38:02I'm sure. Our problems are similar.
01:38:09Yeah,
01:38:10I mean, I think you know PTI labs radiology procedures that need sedation and you know into Bashan.
01:38:16I mean, I think there there are a lot of similar groups were trying to get a work group together at our hospital with all those groups,
01:38:24so that were kind of treated on the same plate as opposed to you know,
01:38:29all living in our own silo is trying to come up with the answers to these sort of similar problems.
01:38:35I think obviously there's a Munich issues that then this leap pads and our long tests and.
01:38:40And you know in different different other issues,
01:38:43but I think there's some basic issues of if you're coming into an outpatient procedure that has a nearest lization risk and you tested negative,
01:38:52what precaution to use?
01:38:56I just want to Echo Karen what you said this is Shannon in that it's it's really a great opportunity to get start communicating with your local anesthesia groups,
01:39:05especially at your hospitals because they're dealing with putting people on ventilators for outpatient procedures that these folks are coming in is while they're gearing up to do this now.
01:39:15At least in Northern California,
01:39:17have patients come in for day procedures and then go home.
01:39:20And you're exactly right. They're dealing with the same issues and they I'm reading one now,
01:39:26I. I have well formed protocols or what to do vis-a-vis testing what level of air,
01:39:31civilization and droplet precautions to use based on testing and symptoms and the one I'm viewing now is one where patients would need to be tested within four days of
01:39:41coming into an ASE. Has a few people have mentioned four days seems awfully lying to me.
01:39:48Maybe that should be shorter,
01:39:50but even in a patient without symptoms and with a negative tasked with a low risk procedure,
01:39:56either with general anesthesia or or without with local standard pbe would be recommended but but.
01:40:02The folks in the room with the patient have the option to Danann 95 or a pepper if they,
01:40:08if they judge the situation,
01:40:10merits it. And as someone else brought up,
01:40:12we also have to remember we need to keep our healthcare workforce safe.
01:40:16And so if you have sleep technologists or respiratory therapists with certain risk factors,
01:40:21that may also be worth considering.
01:40:24Yeah, I don't
01:40:26get that. The greatest good for the greatest number an having an available workforce.
01:40:31Stay as healthy as possible so they can continue being service for the rest of our patients.
01:40:36You know there as valuable resources.
01:40:38Anything we have. So I think that it needs to be made a priority.
01:40:44You know, I think one other issue is a CDC currently does not recommend any health care worker testing unless they're symptomatic,
01:40:52so you know we do have the issue of patients being afraid to come in for the study because it might be the health care worker giving giving it so,
01:41:02specially if there is a health care worker that's going to spend up along time up close to someone's head and face.
01:41:10It may may give the patient.
01:41:12Also, you know that sense that they won't pick it up from the tech who may or may not be,
01:41:20you know, a cobet carrier.
01:41:23Great
01:41:23card there, probably some people on this session or from other countries.
01:41:32How do we sort of get them to give us some information about what their experiences?
01:41:40Yeah. Go ahead and
01:41:42there are particular people at this point.
01:41:44I'd say now that we're late in this if they want to unmute themselves and and wanna try
01:41:50to chime in with our.
01:41:52Are they able to unmute themselves?
01:41:54I believe I made it so they could OK,
01:41:57so if there's anybody there from another country,
01:42:00we'd love to hear from you.
01:42:06I can also give a perspective from other
01:42:10countries from my.
01:42:11Michael. Hello. Imagine.
01:42:20Owner. That became chaotic.
01:42:31OK,
01:42:33so. I guess. Is there someone there who can unmute themselves from another country?
01:42:45I.
01:42:47Yeah, use the raise hand function.
01:42:49And Karen can unmute you specifically.
01:42:53I
01:42:54I think I'm a muted.
01:42:55Can you hear me? Yeah,
01:42:57I can hear you yeah real quick while we wait for others to chime in.
01:43:02I was on a call.
01:43:04As I mentioned earlier with some of the folks in Europe.
01:43:08And just like in the US,
01:43:10sleep labs have essentially closed down in the countries hit hardest.
01:43:14Germany, France, Spain, Italy, the UK,
01:43:16etc. Germany this week is going to begin slowly opening a few sleep labs in selected areas of the country that have been.
01:43:24It was far and they're going to do very slow deliberate rollout using very similar guidelines as the ASM guidelines to slowly reopen,
01:43:37not just sleep labs, but other elective procedures.
01:43:41Another ambulatory
01:43:42services. Good. So I think this might be a good time to come to move on to our next zoom call.
01:43:55Believe it or not I have another zoom call with pulmonary critical care,
01:44:00uh, that starts in 14 minutes.
01:44:02So do you? Do we think it's a good idea to have another one of these in about a month?
01:44:11To see what kind of progress is sort of going on,
01:44:15so let's go ahead and Carne.
01:44:18Should we plan for another
01:44:20month? You're muted. You muted yourself
01:44:26there IJ
01:44:27sure. Alright, so let's plan
01:44:29on about another month to get a sense of of how things are going.
01:44:36And
01:44:37we do have a survey I think are in
01:44:40wants to mention. Um, so I did um post a survey both in the chat and on the slides.
01:44:47And if you need to get it,
01:44:50you can email me otherwise,
01:44:52um, and we're going to try to.
01:44:55I'm hoping send it out in the ASM news blast and other ways to get the link as well.
01:45:02And it's both for text,
01:45:04ansley providers, and it's basically to get providers opinions on issues related to this,
01:45:10so I think we definitely can.
01:45:12You know what I'm gonna be trying to get the data out to everybody,
01:45:16but that that's definitely something that we can help try to present on as well when we meet back again.
01:45:22Yeah, for all of the people who were on the call today,
01:45:26this is your chance to let us know how you're doing and how you're handling business in your labs and what your concerns are
01:45:33in the survey. Does a great
01:45:35job of capturing all the main points,
01:45:37and I know it's have to,
01:45:39but. Appreciate any any comments.
01:45:41I think you know, we tried to cut it down.
01:45:44But there are just so many I think issues from so many areas that people have thought 7.
01:45:51One thing when you do the survey as soon as 10 people have answered it.
01:45:56You start seeing what other people's responses are to the question so I think people will find that really interesting for you know for what?
01:46:05Other people are thinking and saying out there.
01:46:08It takes 10 minutes.
01:46:10Thank you so I'm
01:46:12I'm I'm leaving for my next call bye bye and thanks everybody.
01:46:16We are going
01:46:17to do our best to get this posted.
01:46:20I hope it got recorded appropriately and uh and I an and this was great.
01:46:26Thank you and sorry for the initial little technical issues,
01:46:30but I
01:46:31think we survived.
01:46:32And
01:46:33the next time?
01:46:34The Next One is a webinars so we can get even more people.
01:46:39Thanks very
01:46:40much. Thank you
01:46:41for your
01:46:42leadership. Appreciate it.
01:46:50Thanks very
01:46:51much, Karen.
01:46:52Thank you everybody.