"Impact of COVID-19 on Sleep Centers and Mitigation Strategies" Indira Gurubhagavatula (9.9.2020)
September 10, 2020ID5574
To CiteDCA Citation Guide
- 00:00Points, and this is another
- 00:02picture that shows recent trends
- 00:03in in in this northeastern region
- 00:06compared against California,
- 00:07and we can see that Massachusetts,
- 00:09New York, Connecticut, the cases
- 00:10are still continuing to rise slowly.
- 00:12New Jersey has more cases in the slope,
- 00:15maybe a little bit,
- 00:17but steeper than the other States
- 00:19and California is really taking
- 00:20off with lots of activity.
- 00:22So just remember,
- 00:23when you look at these graphs,
- 00:25there also reflection of how much testing
- 00:28is being done and how available is it in?
- 00:31Are people going to get tested?
- 00:33Anne Anne Anne reporting can
- 00:35really impact these numbers,
- 00:36but they are a place to start.
- 00:40So having said that,
- 00:41when we issued our guidance it is
- 00:44not a fixed firm thing that that
- 00:47applies at any point at anytime,
- 00:49geographically or over the course
- 00:51of the pandemic as things evolve,
- 00:54this really is a living document,
- 00:56and so anytime we're looking
- 00:58at sleep operations,
- 01:00we need to make sure we are
- 01:02adjusting our approach according
- 01:04to what's happening locally.
- 01:06What sorts of rules and guidance
- 01:08or being issued?
- 01:10At the federal level,
- 01:11the state level at local level
- 01:13are are hospital employers and
- 01:14then what is the data saying is is
- 01:17the signs the science can evolve.
- 01:18It can change.
- 01:19We thought it was mainly contact
- 01:21spread and then we discovered
- 01:23it's actually aerosol based.
- 01:24So you know things keep changing.
- 01:26So the guidance this anything
- 01:28about to share with you today is
- 01:30not meant to be prescriptive.
- 01:32Especially given that we have a
- 01:33positive data in many of these
- 01:35recommendations,
- 01:36so it's really considerations and
- 01:37things that we should be thinking about.
- 01:41So we as of July it this is no longer
- 01:44inside the Public Safety Committee,
- 01:46but we're actually convened a task force,
- 01:49and the six people on the left, or members.
- 01:52We have a policy ography technician
- 01:54and respiratory therapist.
- 01:55We have doctor burning King whose
- 01:57occupational medicine expert,
- 01:58we have sleep specialists in Wisconsin,
- 02:00Florida, North Dakota and Chicago, IL.
- 02:02We have an infectious disease
- 02:04consultant and we have a vice chair
- 02:06from Palo Alto Doctor Sullivan.
- 02:08We also work with Doctor Rimar,
- 02:10who's the current president.
- 02:11The ASM and service,
- 02:13our liaison with the board of directors.
- 02:16Doctor Epstein and Mr Heffron.
- 02:17Our staff members and I'm serving his chair.
- 02:23So we put all of our heads together
- 02:25an in our latest revisions,
- 02:27an update to the online guidance.
- 02:29We grouped all our recommendations
- 02:31into three categories and
- 02:32they're there for your review,
- 02:34and I encourage everyone to to
- 02:36take a look and see what you,
- 02:38whatever you need it is.
- 02:39We tried our best to make
- 02:42sure that it's there for you.
- 02:45All the FAQ we continue to
- 02:47receive submissions on line and
- 02:49we have up to 15 of them now.
- 02:51We've kind of lump them all
- 02:53together in different categories.
- 02:54For sleep clinicians.
- 02:55We also took all the recommendations
- 02:58that the CDC has issued along
- 02:59the way and went through the all
- 03:01the volumes of information and
- 03:03cleaned out the portions that
- 03:05are relevant for sleep practices,
- 03:06and we summarize them in a convenient way.
- 03:10And then we have 1/3 tab that
- 03:13includes specific considerations
- 03:14for Sleep Medicine that are not
- 03:16discussed by the CDC and that we've
- 03:19come up with based on consensus and
- 03:21using the best available evidence.
- 03:24So as far as the FA cues, as I mentioned,
- 03:27there are 15 different ones,
- 03:29but I'm not going to go through all of
- 03:31them now, but they cover things like.
- 03:33How do you decide if your lab should
- 03:35close and when it should reopen?
- 03:37What sorts of information should
- 03:39you be consulting?
- 03:40What number should you be looking at?
- 03:42And then how do you?
- 03:43What types of strategies and control
- 03:45should be thinking about to mitigate
- 03:46viral transmission risk among your
- 03:48personnel inside your facility?
- 03:49What sort of environmental controls
- 03:51should be should be thinking about an?
- 03:53What kind of strategies to use an
- 03:55outpatient practices in the lab?
- 03:57What should you tell a patient if they say,
- 03:59hey, I I'm not?
- 04:00I'm worried that the see Pap Machine is
- 04:02gonna blow the virus further into my lungs.
- 04:04What sorts of advice should be giving our
- 04:07patients about C Pap if they get sick?
- 04:09And what're payer policy saying?
- 04:11So all of that is in there.
- 04:14the CDC recommendations that are relevant
- 04:17for us were categorized into three groups.
- 04:20The first includes patient care strategies.
- 04:23the CDC issued this guidance in
- 04:26mid July and there they said they
- 04:29were concerned that patients who
- 04:32really needed health care services
- 04:34were not showing up,
- 04:36and so they issued guidance
- 04:39on how to reopen facilities.
- 04:42So patient care strategies.
- 04:43the CDC was really recommending Tele
- 04:46Medicine and how to go about doing that.
- 04:48They were also looking at how
- 04:50do you prescreen patients before
- 04:52they arrive at your facility?
- 04:53When should you use COVID-19 testing?
- 04:55They also provided strategies
- 04:57for healthcare providers in the
- 04:58in the workplace setting.
- 05:00How do you protect yourself so they have
- 05:03guidance on what types of PP should you use?
- 05:06When is it appropriate?
- 05:08Use which type of PPE?
- 05:10And then finally cleaning instructions
- 05:14for health equipment and facilities.
- 05:19And then finally the third category,
- 05:21or all the unique and special
- 05:23considerations that need to be taken
- 05:25into account in sleep centers.
- 05:27So outpatient practices in laboratories.
- 05:29And there we used our consensus
- 05:31to come up with recommendations,
- 05:33and that's where we'll be spending
- 05:35the rest of today talking about.
- 05:38So those recommendations that apply
- 05:40specifically to Sleep Medicine,
- 05:41we categorize them into five areas.
- 05:43The first is your general approach
- 05:46to care delivery and what kind
- 05:48of model are you going to use.
- 05:50We can't continue to do face to
- 05:53face visits and lots of in lab
- 05:55tests in this environment,
- 05:57and so how do we go about
- 05:59delivering care using other models?
- 06:01The second has to do with pre testing
- 06:04patients before they show up for COVID-19.
- 06:07The third has to do with diagnostic and.
- 06:10Titration studies and in home testing
- 06:12the 4th category has to do with therapy
- 06:15consideration specifically related to C Pap.
- 06:18And then finally,
- 06:18how do you mitigate risk in your
- 06:21own practice?
- 06:22So let's look at care delivery.
- 06:24So first and foremost,
- 06:25any plan that you come up with
- 06:27or that you're thinking about
- 06:29has to conform with local rules,
- 06:31regulations and emergency orders,
- 06:32and so there are a number of areas to look.
- 06:35One is within your own institution
- 06:37or hospital,
- 06:38the other is the local guidance
- 06:40or regulations and then state
- 06:42and regional and national,
- 06:43and these can change and they
- 06:45can change very quickly.
- 06:46And it's a lot of information to go through.
- 06:50So it's important that your practice
- 06:51stays up to date on this information,
- 06:54so we had advised that you consider
- 06:57actually appointing someone whose
- 06:58responsibility it is to stay on
- 07:00top of all of this information and
- 07:02translate it for the rest of your team.
- 07:05And everything else flows from this.
- 07:07All the other decisions you
- 07:10make fluid flow from this.
- 07:12So next,
- 07:13uh,
- 07:13once you decide on other
- 07:15care delivery models,
- 07:17think about when it's appropriate
- 07:19to use other modes.
- 07:21So if cases arising and your locality is
- 07:24concerned about a new outbreak happening,
- 07:27and that the hospital is starting to fill up,
- 07:31it's a really good time to move
- 07:34to Tele Medicine approaches
- 07:35and not at the last minute,
- 07:38but preemptively start calling
- 07:40patients and converting them over.
- 07:42But are there newer return visits?
- 07:45Start moving them over and this
- 07:47is a function of is it possible at
- 07:50all there are there are accredited
- 07:52facilities that simply cannot take
- 07:55this on because they don't have
- 07:57the resources and as a result at
- 08:00the ASM actually offered free use
- 08:03of their telemedicine platform.
- 08:05During the pandemic, but but is it available?
- 08:07Is it feasable how much work does
- 08:09it take to onboard patients?
- 08:11And as your staff having to spend
- 08:13hours getting them to download a
- 08:14specific software and making sure they
- 08:16have a login ID and that it works,
- 08:18and they know how to do it,
- 08:20or all your clinicians uniformly
- 08:22trained and they're comfortable in
- 08:24getting enough on and off and
- 08:25in and out of these visits?
- 08:27And will patients actually
- 08:28accept it and agree to use it?
- 08:30So a lot of things to be looked at
- 08:32and considered as you rollout Tele
- 08:34Medicine and then another group that.
- 08:36Provides patient care or the DMV providers.
- 08:38The restaurant therapist who do the
- 08:41mass fittings and we have a C Pap
- 08:44clinic on site where patients could
- 08:46just walk in which has since been
- 08:48closed and so offering mass fittings
- 08:50remotely is another area that's evolving.
- 08:52There are some software that's coming
- 08:54out that can help with 3D image Ng,
- 08:57so moving forward that could change and
- 08:59we could have other resources available.
- 09:02And then use remote monitoring when you can.
- 09:05So instead of having patients show
- 09:07up with a C Pap machine that needs
- 09:09to be downloaded or an SD card,
- 09:12consider outfitting all of these
- 09:13devices with modem so that you can
- 09:16have remote access to their data.
- 09:18And there are some reimbursement
- 09:19codes that are available.
- 09:21They are on the SM website so that
- 09:23some of that activity is billable.
- 09:25And then consider using home based testing.
- 09:28So when are in our area when when
- 09:30there was a big spike in cases, a Cup.
- 09:33Two months ago,
- 09:34we actually closed our lab and resorted
- 09:37entirely to home based testing,
- 09:38and at the VA for awhile.
- 09:40They weren't doing either.
- 09:44And then next as you come up with
- 09:47these care delivery models be
- 09:49very clear and very specific with
- 09:51the algorithms that you develop,
- 09:54so there's no confusion around what
- 09:57to do or how to do it can see.
- 10:00You're allowing patients
- 10:01to assess themselves.
- 10:02They know when to seek care,
- 10:04so having advice lines or using the
- 10:07electronic patient portals offering on
- 10:09line assessment tools so that patients
- 10:11know when they need to come in,
- 10:13get evaluated, get tested,
- 10:16and so forth.
- 10:17Number of such questions can
- 10:19increase some practices.
- 10:20Referral practices decrease their
- 10:22business or close their doors,
- 10:24so some of those patients were were no
- 10:26longer able to access the lab directly.
- 10:29So giving patients access to this Direct
- 10:32Line of self evaluation can be very helpful.
- 10:36And in the process of closing down
- 10:38certain services or postponing them,
- 10:40think about how are you going to make
- 10:43sure those patients don't end up lost.
- 10:45And then when you do reopen
- 10:47and re offer those services,
- 10:49how are you going to prioritize
- 10:51and triage patients?
- 10:52So have something in place so that
- 10:54you continue to maintain access
- 10:56to care for patients have been
- 10:59postponed and that there is a
- 11:00way to get them back in quickly.
- 11:02The more emergent ones and then this is
- 11:05special group safety sensitive workers.
- 11:07So truck drivers and so forth.
- 11:09And they're offering important
- 11:10services during the pandemic,
- 11:11many of them when they show up to you,
- 11:14they have time sensitive licensure.
- 11:16They need to be evaluated
- 11:18and treated very quickly.
- 11:19So if there's a big run on home testing
- 11:21devices because your lab is closed
- 11:23and they now have to wait longer,
- 11:25you gotta think about can you come up
- 11:26with the priority system so they can.
- 11:28They can sort of jump the line
- 11:31and get tested earlier.
- 11:32And then think about how are you
- 11:34going to handle people who are
- 11:37showing up with your patient.
- 11:38The CDC recommends that visitor
- 11:40policies be put in place so that
- 11:43unnecessary visitors or restricted
- 11:44from entry in many hospitals
- 11:46have these in place as well,
- 11:48but some patients need family members
- 11:50to help them with because they're
- 11:52medically necessary to be there.
- 11:54Sometimes their actual medical
- 11:55personnel or attendance,
- 11:56sometimes translation services are needed.
- 11:58So how are you going to screen those people?
- 12:01What advice are you going to
- 12:03tell them you know?
- 12:05Are we going to have masks available?
- 12:07Do they need to be pre tested for COVID-19?
- 12:10All of that needs to be thought
- 12:12about and for us in our practice
- 12:14as far as translation services,
- 12:16we are using electronic.
- 12:18We have a number that we call so that
- 12:21we have somebody readily accessible.
- 12:23And then think about what to
- 12:25do for those who show up,
- 12:26and they say I'm not wearing that mask or
- 12:28and they don't maintain social distancing.
- 12:30Have a policy in place so that your
- 12:33staff are not caught off guard.
- 12:35And then there may be a time when a covid
- 12:39cases actually linked to your lab,
- 12:42or someone who visited your
- 12:44lab or works at your lab.
- 12:46So make an active effort to
- 12:49participate in local contact tracing,
- 12:51and all of this, all of these policy's
- 12:53need to flow from emergency orders,
- 12:56regulations policy's guidance
- 12:57issued by your institution,
- 12:59and by local, state,
- 13:01and national authorities.
- 13:04Now as far as Covid Pretesting.
- 13:09Pretesting the decision to use pre
- 13:11testing or not is can be run by just
- 13:15isn't even available in your area and
- 13:17how long does it take to turn around
- 13:20and what are the rules around it?
- 13:22And are there rules were certain
- 13:24patients have to get tested?
- 13:26So for example somebody who just
- 13:28came out of a high risk area or had
- 13:31a recent exposure now plans to work
- 13:34in Healthcare so the turn around time
- 13:36in some places has gotten very long
- 13:38when we first started in our facility.
- 13:41Doing covert pretesting,
- 13:42we were able to get results back relatively
- 13:45quickly within one to three days,
- 13:47but now it's taking longer and so
- 13:49if if it's taking 10 days seven days
- 13:51it might almost not be worth it
- 13:54because there's risk of re exposure
- 13:56if they were tested 10 days ago.
- 13:58And then you're planning to
- 14:00do your titration tonight,
- 14:01it's not clear what their
- 14:03covid statuses anymore,
- 14:04so you need to think about.
- 14:07Whether that's the right way
- 14:09to go and then the context,
- 14:11so a negative test would be having a
- 14:14negative test on hand would be helpful
- 14:16if you're doing a more risky procedure,
- 14:19like a titration,
- 14:21which can be potentially aerosol
- 14:23generating versus a diagnostic
- 14:24test where the need for testing
- 14:26may not be as significant based
- 14:29on what's happening locally.
- 14:30And it's also important to
- 14:32interpret these results in the
- 14:33context of pretest probability,
- 14:35which is a function of local prevalence.
- 14:37So if you have a highly prevalent condition,
- 14:39if covid is is,
- 14:40if there is a major spike in activity
- 14:43and you have a negative test result,
- 14:45then you gotta look at that
- 14:47with a little bit of.
- 14:49You gotta question that result,
- 14:50and is it a false negative?
- 14:52And similarly test methodology with
- 14:54the nasopharyngeal swabs at this?
- 14:55Not swab isn't put in all
- 14:57the way or done correctly.
- 14:59You can get a false negative test.
- 15:01So if it doesn't fit the picture,
- 15:03the person might need to be retested.
- 15:05So if they have symptoms, for example.
- 15:08Or there is a very high prevalence area,
- 15:10or there's a high suspicion
- 15:12that they have a negative test.
- 15:13May not be as meaningful and similarly
- 15:15in a very low prevalence area of
- 15:18false positive test as possible.
- 15:19So, and it's important to have a policy
- 15:21in place where you think about, well,
- 15:23how are we going to handle a positive result?
- 15:26What's the next thing that needs to happen?
- 15:28Who do we refer to?
- 15:30Who we call?
- 15:31How do we get that patient managed?
- 15:33So in terms of covid status,
- 15:34if someone has been tested
- 15:36their different categories,
- 15:37they can fall into,
- 15:37they may be someone who is currently
- 15:39under quarantine or presumed positive,
- 15:41or their status is unknown.
- 15:43Or they may be presumed to be
- 15:44negative or completely recovered.
- 15:46And really we should not be
- 15:47bringing people into our lab who.
- 15:49Or anything other than presume
- 15:51negative or recovered.
- 15:54And then as far as sleep
- 15:57testing considerations.
- 15:58If we, when we when are disease
- 16:01activity was at its peak in April,
- 16:04may we actually closed our lab
- 16:06and we went to home testing.
- 16:08And so if you implement that
- 16:10type of home testing protocol,
- 16:12then in the in the execution of that
- 16:14protocol it's important to continue
- 16:16to maintain the principles of social
- 16:19distancing and contact precautions.
- 16:21So we adopted initially a male model
- 16:24where we would Mail the device and
- 16:27they would Mail it back to us.
- 16:29One of the concerns with that
- 16:31is that the Mail service has
- 16:33gotten very slow and the demand
- 16:35for these devices has increased,
- 16:36so it becomes a bottleneck and it
- 16:39ends up limiting access to care.
- 16:40So we then switched to curbside the
- 16:43curbside exchange model and think about,
- 16:45you know if you're going to do that,
- 16:47make sure that you have
- 16:49scheduled appointments.
- 16:49You don't have a big buildup of people
- 16:52all in a big crowd waiting to turn it in,
- 16:55so it really is they drive by.
- 16:57They handed up a hand it to the.
- 17:00To the hospital personnel
- 17:02and then they leave,
- 17:03and likewise the dispensation
- 17:05and the retrieval occur.
- 17:06That way outdoors,
- 17:07and then the instruction that we were
- 17:10doing initially was face to face.
- 17:12But we've had to be adaptive,
- 17:14and so think about doing this
- 17:16to maintain social distancing,
- 17:18where using either printed both
- 17:20shores or get away from that.
- 17:22So you're not worried about context
- 17:24transmission and use electronic
- 17:25ways of instructing either video
- 17:27that can be viewed asynchronously,
- 17:29or Tele medicine visits where you're
- 17:31actually. Providing life support.
- 17:35And then, uh,
- 17:36after Retrieval and handling the package
- 17:38follow contact based precautions.
- 17:39Consider using single use.
- 17:41Store fully disposable devices.
- 17:42Some labs are doing that,
- 17:44others are finding it cost prohibitive.
- 17:46Others are using component parts that
- 17:49are disposable and others that are reusable.
- 17:51And if you are using a reasonable device,
- 17:54make sure you're thinking about
- 17:56what are the CD CDC recommendations
- 17:58on cleaning and disinfection?
- 18:00What is the manufacturer saying and
- 18:02do you have facility policy's and
- 18:04the technologists are handling this?
- 18:06Spices should be using appropriate
- 18:08PP for that activity,
- 18:09and some labs are actually waiting
- 18:1172 hours and taking the device
- 18:13out of service for that period
- 18:15of time before they dispense it
- 18:16again to the next patient.
- 18:18So where did that come from?
- 18:20So that was from this study that
- 18:22was published in The Lancet.
- 18:24In April an what this group did was
- 18:27they took a 5 microlitre aliquots
- 18:30of solution that had virus in it
- 18:33and they put it on a variety of
- 18:36services services and then they went
- 18:38back and they checked to see could
- 18:41live virus be retrieved using viral
- 18:43transport media from the surface is
- 18:46and they found that in on plastic
- 18:48that the virus live virus could be
- 18:51retrieved in three after three days.
- 18:54So this doesn't mean that you
- 18:56can that that that
- 18:57translates into active infection.
- 19:00In fact, we don't know of cases where
- 19:02the the only source of transmission
- 19:04was through handling mailed packages,
- 19:07but one of the principles we appear
- 19:09to was airing on the side of caution
- 19:12and in the interest of Public Health,
- 19:15some labs are following that and keeping
- 19:18these devices out of service for three days.
- 19:22Now, what about laboratory
- 19:23based testing here?
- 19:24Our group felt that it was important
- 19:27to weigh patient preferences against
- 19:28clinical judgment to determine
- 19:30whether the study should be done in
- 19:33the lab or should be done at home.
- 19:34So you may have a patient that says, yeah,
- 19:37I could do it at home, but I really cannot.
- 19:41You know there are eight people
- 19:43who sleep here.
- 19:44It's too noisy. It's too cold.
- 19:46I'm too stressed.
- 19:47I'm not safe, so they may strongly
- 19:49prefer to come into the lab.
- 19:51And if the.
- 19:52Pair reimbursements,
- 19:53or is willing to cover that,
- 19:55then then that's an option,
- 19:57but on the other hand,
- 19:59if it's somebody who.
- 20:00As risk factors for severe COVID-19 you have
- 20:03questions about you know what would happen,
- 20:06whether they might be infected,
- 20:07or if they were to get infected,
- 20:10then the result could be catastrophic.
- 20:12So somebody who recently had cancer,
- 20:14chemotherapy, or you know,
- 20:16is the sole breadwinner for their family,
- 20:18and they are in a high risk
- 20:20group for severe COVID-19.
- 20:22So someone like that,
- 20:23you may want to try to get by with
- 20:26with home based testing strategies,
- 20:29and if they are appropriate
- 20:31based on the clinical setting.
- 20:34To help you with the C,
- 20:36ASM does have practice guidelines
- 20:39available for both diagnostic
- 20:41testing and also for the delivery
- 20:44of positive airway pressure.
- 20:46The other thing you can consider
- 20:48is actually using Empirix C Pap.
- 20:50So instead of Poly Sonography
- 20:51you can try auto titrating,
- 20:53see pap or just empiric C Pap
- 20:55without any kind of testing.
- 20:57So how do you decide who should get
- 20:59that type of therapy where you're
- 21:02just kind of looking at them and
- 21:04saying yeah I think you can try C Pap.
- 21:07So rather than just kind of rule
- 21:09of thumb in it there are screening
- 21:11and assessment tools.
- 21:12We had a task force that looked at this.
- 21:16And published all the tools that
- 21:19are available and that is available
- 21:21in the JCSM in the July 2018 issue.
- 21:24The The The.
- 21:25The thing about these tools is that
- 21:27there is no specific threshold.
- 21:29So if you have a score on a stop bang
- 21:32of X or your Berlin questionnaire
- 21:34result is why then that person
- 21:37can go straight to Empiric C Pap.
- 21:39We don't have that kind of criteria
- 21:42that validated so so some of this is
- 21:44going to have to be based on clinical
- 21:47judgment and the best guess and the
- 21:49best clinical expertise of the evaluator.
- 21:51There is a tool that we
- 21:53developed at our institution.
- 21:55The multivariable apnea prediction score.
- 21:57And that's also included in
- 21:59this in this assessment review
- 22:01document and there the score goes
- 22:03from zero to one and at the VA that
- 22:06you know pre testing with PSG,
- 22:08RHS 80 is not required
- 22:10before C Pap dispensation.
- 22:11So this is something we've been able
- 22:14to do and have done for a few years now.
- 22:18And we used a threshold score
- 22:21of .7 and found that.
- 22:23The adherence with C Pap after
- 22:25that appeared to be similar to
- 22:27those who didn't get testing.
- 22:29Now that was a different model care
- 22:31delivery model where the patient was
- 22:34assessed and then within one to three days,
- 22:36sometimes the same day.
- 22:38They had a live in person,
- 22:40extensive education and face to face.
- 22:42C Pap set up.
- 22:43So this environment under COVID-19
- 22:45is quite different from that
- 22:47where there drop shipping C pap
- 22:49machines to patients homes and
- 22:51live in face to face education.
- 22:53There hasn't been as readily available,
- 22:55so how well it would work is is unknown,
- 22:58but Medicare has now will cover C
- 23:00Pap based on clinical assessment
- 23:01without diagnostic testing,
- 23:03and they have not clarified whether
- 23:05at some point down the road
- 23:07the patient should get tested.
- 23:08Once this emergency is over.
- 23:11Now let's think about C Pap itself.
- 23:14So in order to understand C Pap,
- 23:16we gotta look at the way that
- 23:19the virus transmits.
- 23:20So there are different types of transmission,
- 23:22and it appears when a person coughs,
- 23:25sneezes,
- 23:25or talks,
- 23:26or even exhales droplets escape
- 23:28from the nose mouth and the larger
- 23:30ones will drop immediately,
- 23:31inform the person and not travel as far,
- 23:34but the smaller ones are the ones
- 23:37that can stay airborne and where the
- 23:39virus stays ERISA Lizet they can travel.
- 23:42A lot longer,
- 23:43not farther distance in stays suspended
- 23:45in the air for a longer period of
- 23:47time where they can be inhaled,
- 23:49so Ebola is contained in these
- 23:51larger droplets that fall,
- 23:53and so contact based transmission
- 23:54is a is a more significant method
- 23:56of transmission.
- 23:57But measles chicken pox,
- 23:58they can stay suspended in aerosol
- 24:00form and travel much farther,
- 24:02so the coronavirus is probably
- 24:04somewhere in the middle,
- 24:05which is where the six feet
- 24:08distancing rule comes from.
- 24:10So the initial suggestion that
- 24:12this isn't just contact for,
- 24:13but maybe you're born came out of
- 24:15the restaurant in the Guangzhou
- 24:17Province in China,
- 24:18where an infected person he didn't
- 24:20know they were infected at the
- 24:22time that they had this meal with
- 24:24a bunch of family members and later
- 24:26that day they went and got tested
- 24:29and were confirmed to be positive
- 24:31and eventually over the course of
- 24:33the next few days a number of people
- 24:35who sat at the same table and we're
- 24:38from the same family got infected.
- 24:40But also people unknown to this family,
- 24:42two other families that were
- 24:44happening to be sitting in adjacent
- 24:46tables also had infected members.
- 24:48So total of nine people got infected here,
- 24:50whereas 8 staff members and 70
- 24:52three other people who were in the
- 24:55restaurant at the same time tested negative.
- 24:58And so it was traced back to this air
- 25:00conditioning unit and that the air was
- 25:02blowing one way out and then reverse flow
- 25:05was happening in the other direction.
- 25:07And so everybody who sat in front of this
- 25:09air conditioner ended up getting sick and
- 25:12then a second occurrence in the Skagit
- 25:14Valley Choir in Washington on March 10th.
- 25:16This group took all sorts of precautions
- 25:18they handed out sanitizer at the door.
- 25:21Nobody shared sheet music.
- 25:22There was no hugging or kissing
- 25:24or close contact.
- 25:25People stood away from each other and
- 25:27nobody was known to have been sick.
- 25:29Just like at the restaurant,
- 25:31nobody had symptoms,
- 25:32nobody was coughing or sneezing,
- 25:33and yet 75% of the people who
- 25:36attended got infected by one person.
- 25:39Who happened to be infected?
- 25:40So what this exposed was that
- 25:43transmission before people develop
- 25:44symptoms is possible and that in
- 25:46fact 80% of infections that are out
- 25:49there are thought to come from a
- 25:51minority of these super spreaders so
- 25:5320% or so people end up infecting
- 25:56lots of others by just being at
- 25:58the wrong place at the right time.
- 26:01So the Super spreaders in a
- 26:04super spreading event.
- 26:05And then as far as the emergence
- 26:08of airborne transmission inside
- 26:09healthcare workers with this
- 26:11particular virus that that started
- 26:13emerging early on when universal
- 26:15masking wasn't necessarily the norm.
- 26:17But Wu Hon started noticing a
- 26:19disproportionate number of cases
- 26:21and deaths among anesthesiologists,
- 26:23critical care specialist and ophthalmologist,
- 26:25an EMT specialist, and Iran,
- 26:27where at least 220 NT Surgeons
- 26:29were hospitalised.
- 26:30There were twenty more placed in isolation,
- 26:33and one resident actually had a cardiac
- 26:36arrest because of my carditis in Britain,
- 26:39reported 2 E NT doctors on Ventilators,
- 26:42and Stanford issued a white paper
- 26:44saying that your nose and throat in
- 26:47any other specialties that do high
- 26:49risk procedures like intubation,
- 26:51endoscopy, Bronx or layering,
- 26:53osca,
- 26:54P or at risk for increased risk
- 26:57for transmission because of high
- 26:59viral shedding from the from the
- 27:02nasopharynx in the oral fairings.
- 27:05So as of now,
- 27:06in addition to these procedures
- 27:08like Endoscopy and learning Osca P,
- 27:10the CDC also considers C Pap and Bipap
- 27:12to be aerosol generating procedures.
- 27:14So what that means is that the virus
- 27:17can stay in higher concentrations
- 27:19and can travel a much longer distance
- 27:22and it can stay in the air longer
- 27:24than just somebody who's infected,
- 27:26who's coughing, sneezing,
- 27:27talking or breathing.
- 27:28So there's a higher risk of exposure and
- 27:30infection for those who are hanging around.
- 27:33People who are on C Pap or Bipap.
- 27:36And data for this also came out of
- 27:38the first SARS epidemic in Toronto,
- 27:40where half of all of the cases that
- 27:43were transmitted in the hospital
- 27:45were in health care workers.
- 27:46Three of them died,
- 27:47and they seem to happen during
- 27:49the delivery of nebulae.
- 27:51Zehrs,
- 27:51high flow oxygen and definitely
- 27:53positive pressure ventilation.
- 27:54So then the next question is,
- 27:56is there a way that we can
- 27:58kind of mitigate
- 27:59that risk and or some masks
- 28:02actually less risky than others?
- 28:04The data on all of this is very,
- 28:06very low right now,
- 28:08including the use of other things like viral
- 28:10filters and other adaptive technologies,
- 28:12but this study done by huy in the
- 28:15European respiratory Journal looked
- 28:16at two types of nasal pillows,
- 28:19and they compared this against
- 28:20one type of full face mask,
- 28:22so it was very specific.
- 28:24Brands that they tested and
- 28:26they tried increasing levels of
- 28:28continuous positive airway pressure.
- 28:30And this these were not actual patients.
- 28:33This was a mechanical patient
- 28:34simulator and what they found was
- 28:37that with increasing C Pap pressure,
- 28:39the dispersion distance increased
- 28:40and if they simulated lung injury
- 28:42than the dispersion was even.
- 28:44Even worse went even farther,
- 28:46and similarly they saw a similar
- 28:48pattern with the use of high
- 28:50flow nasal cannula oxygen,
- 28:51whereas with the full face mask they
- 28:54did not see that type of dispersion.
- 28:56But it turns out they were
- 28:59measuring dispersion of smoke.
- 29:00In the sagittal plane directly in front
- 29:03of the patient and this full face mask
- 29:05that they evaluated had the exhalation ports,
- 29:08the isolation holes were in a circle evenly
- 29:11distributed around the elbow connector,
- 29:13so there couldn't be a stream
- 29:14for them to measure because the
- 29:16exhaled air was being dispersed in a
- 29:19circumference around the connector,
- 29:21so we don't know for sure that that
- 29:23mask is necessarily safe to use,
- 29:26because the data and the
- 29:28model that they used,
- 29:29and it's only one mass that they tested.
- 29:32So we can't say for certain that a
- 29:35specific mass type is better than others.
- 29:38Now the other question is then,
- 29:40in this scenario,
- 29:41should home C Pap be continued in someone
- 29:44that you suspect might have COVID-19?
- 29:46Or if you know that they have it?
- 29:49So in that case what we suggested is
- 29:51that you gotta really look at what is
- 29:54the risk to the patient of discontinuation.
- 29:57What is the risk to
- 29:59others of continuation so?
- 30:01We recommended that the any
- 30:02decision to either continue or stop.
- 30:04He based on a risk benefit assessment.
- 30:07So what that means is that you take
- 30:09a look and see what are the risks of
- 30:12stopping C Pap for just the short term
- 30:15until the person recovers from COVID-19,
- 30:17and for most people it shouldn't
- 30:19be a big deal.
- 30:21They should be able to get
- 30:23off without issues,
- 30:24but there is a subset of patients
- 30:26who may be at risk for acute
- 30:29cognitive decline or motor problems.
- 30:31Coordination, falling cardiovascular events,
- 30:32arrhythmias, and so forth.
- 30:34And some who may be at risk
- 30:36for driving accidents.
- 30:38Now they shouldn't be driving.
- 30:40They should really be quarantining.
- 30:43But the question if you decide to
- 30:45stop C Pap is then can we actually
- 30:48manage the risk that could result from
- 30:51that for this subgroup of patients.
- 30:53So one thing you can consider in
- 30:55giving such advice is than look
- 30:58at offering fall precautions,
- 30:59refer them back to their cardiologist.
- 31:01Make sure that their medical
- 31:03management management is optimized,
- 31:05advise them against do it using any kind
- 31:08doing anything risky where they could
- 31:10have an accident or hurt themselves,
- 31:12and then look at other
- 31:14forms of bridge therapies.
- 31:15So if they already have an oral appliance,
- 31:18go back and use that.
- 31:20Consider position therapy.
- 31:21Either pruning the patient or using a wedge,
- 31:24pillow, or sleeping upright in a chair,
- 31:27staying away from alcohol,
- 31:29sedating medications,
- 31:29keeping any nasal congestion under control.
- 31:33So the risk of choosing to continue this
- 31:35C pap in somebody who may be actively
- 31:38infected is really the risk potentially
- 31:40of transmitting the infection to others.
- 31:43Knowing that with the increased
- 31:44pressure there could be the issue of
- 31:47the virus could hit surface is that
- 31:49you didn't even think of cleaning like
- 31:51the ceiling or much farther away.
- 31:55And can the risk then to others
- 31:57is that manageable?
- 31:59So can the patient completely
- 32:01quarantine self isolate,
- 32:02have their own bathroom and protect
- 32:04their other household Contacts?
- 32:06Or do they live in a very congested,
- 32:09crowded environment where
- 32:11it's impossible to isolate?
- 32:13Where they are they in a multi unit
- 32:16dwelling which shared ventilation
- 32:17systems where it's easy for viral
- 32:20dispersion outside their home?
- 32:22Even so,
- 32:22these are all things that should
- 32:24be under consideration and then
- 32:26in the inpatient setting there's
- 32:28more information that's available.
- 32:30So patients should have some
- 32:32kovid testing results perhaps,
- 32:33and so looking at what is the
- 32:36hospital saying for patients
- 32:37who have pending covid tests?
- 32:39And what is that? What is their policy?
- 32:42What is the local health department's policy?
- 32:45At the very least,
- 32:47you should be looking at CDC recommendations.
- 32:49On protecting one mitigating risk during
- 32:52a GPS aerosol generating procedures in
- 32:54someone who's COVID-19 test is pending.
- 32:57If you suspect that they have it or
- 33:00that they definitely tested positive,
- 33:02then the we should attempt to avoid
- 33:05positive pressure therapy as much as
- 33:08possible in specific environments where
- 33:10there's an absence of ventilation,
- 33:12you don't have a negative pressure room.
- 33:15The staff don't have adequate access
- 33:17to PPE or other mitigation strategies.
- 33:20An if the test is negative,
- 33:23make sure you interpret that in
- 33:25the appropriate clinical context.
- 33:26So think about the possibility
- 33:28of a false negative test.
- 33:30If your pretest probability is very high.
- 33:32So if the patient appears to be sick,
- 33:35or you suspect that they have it.
- 33:38If the region has a very high
- 33:40penetration of cases and then
- 33:42look again at the environmental
- 33:44factors and environmental controls,
- 33:45what is the ventilation like?
- 33:47Do you have access to pee pee?
- 33:51And if you absolutely have to use C Pap,
- 33:54try using alternate therapies instead,
- 33:56like raising the head of the
- 33:58bed prone positioning,
- 33:59using oxygen as a bridge therapy,
- 34:02and importantly in any of these patients,
- 34:04limit airway procedures and anything
- 34:07that can increase their civilization.
- 34:09And then finally,
- 34:10let's look at mitigating risk
- 34:12within your practice.
- 34:13Here we refer to personnel to
- 34:16facilities and two equipment.
- 34:18So in terms of personnel,
- 34:20in order to really mitigate risk,
- 34:22it's important that personnel have access
- 34:24to educate their well educated or informed,
- 34:27and they know what's going on,
- 34:30and so that means educating
- 34:32personnel about you,
- 34:33know screening symptoms,
- 34:34hand washing, physical distancing,
- 34:36how to recognize if they have symptoms.
- 34:39And and what are your facility
- 34:41sick leave policy's?
- 34:42When should someone go to employee health?
- 34:45Make sure that they are aware of how
- 34:48to put on and take off paper suits.
- 34:51How do you decide which type of PP is
- 34:54appropriate given what you're about to do?
- 34:56So a high risk exposure may require
- 34:59higher levels of pbe than something
- 35:01that's a lower risk exposure and
- 35:03then look at availability of PP.
- 35:05Make sure that it's available before opening
- 35:07up services that you can protect your staff,
- 35:10and if someone is exposed then look at
- 35:13employee health and what is their guidance a.
- 35:16When should the person be tested versus
- 35:18Self Quarantine at home and isolate?
- 35:20Should they continue to report for work
- 35:22and what are the criteria for that?
- 35:24One is a safe time to return to work?
- 35:27And if someone one of your
- 35:29staff has symptoms,
- 35:30make sure that they know that they
- 35:32should not report to work under those
- 35:34situations and make sure the lines
- 35:36of communication and all these policy
- 35:38changes that are clear and open in fact,
- 35:41consider setting up regular,
- 35:42ongoing recurring meetings so
- 35:44that everybody is on board.
- 35:46Now the ASM recommends that the patient
- 35:48to technology ratios that you should
- 35:50have one technician to every two
- 35:52patients under usual circumstances.
- 35:54If you're doing, it in lab sleep study.
- 35:58But the guidance that we offer
- 36:00suggests that COVID-19 concerns could.
- 36:02They're not usual,
- 36:03they could be considered unusual,
- 36:05and so you think about whether
- 36:07other ratios are appropriate,
- 36:09and some of that may have to
- 36:11do with local prevalence,
- 36:13technologist factors.
- 36:14They may be some text who just don't feel
- 36:18comfortable taking on more than one patient.
- 36:21And so there are a lot of other
- 36:23criteria that need to go into into play.
- 36:26Sometimes you know during peaks
- 36:27of activity we actually had text.
- 36:29Who were you could have text to
- 36:32or furloughed text her out sick or
- 36:34who got redeployed.
- 36:35So make sure that the ones that
- 36:37are there they may be taxed.
- 36:39They may be doing other activities like
- 36:41onboarding patients in Tele health,
- 36:43so under that that type of stressful
- 36:45situation make sure that the workforce
- 36:47that you do have has access to
- 36:49adequate rest breaks and that sick
- 36:51leave policy's for them are flexible,
- 36:53that they're consistent with
- 36:54public health guidance, and that.
- 36:56Your fat,
- 36:57your employees actually know what
- 36:59they are in terms of the facility.
- 37:01Think about how can you promote social
- 37:03distancing inside your facility.
- 37:05So Tele medicine obviously is
- 37:07a great way to do it.
- 37:09But then,
- 37:10if you're offering in person services,
- 37:12look at your layout.
- 37:13How can you avoid crowding?
- 37:15What preemptive strategies can you
- 37:17take where you setting up your chairs?
- 37:19Use distance markers?
- 37:20Avoid pileup of patients and
- 37:22check in and check out areas.
- 37:24Make sure sanitizer and PPER available.
- 37:27And that there are signs everywhere
- 37:29reminding patients and staff to to have their
- 37:33masks on and then talk to your building.
- 37:36Environmental control staff About Air
- 37:37Quality and what type of ventilation
- 37:40and filtration systems are in use.
- 37:42And is it possible to even consider using
- 37:46outdoor spaces for providing education
- 37:49sessions or for dispensing equipment?
- 37:52And then make sure you're looking
- 37:54at CDC recommendations for cleaning
- 37:56and disinfecting equipment in rooms
- 37:59and manufacturers themselves can
- 38:00offer cleaning information about
- 38:02equipment as well as the CDC,
- 38:04so the other question that comes up
- 38:07with equipment is if a patient had
- 38:10COVID-19 UC pap and then recovered,
- 38:12what should you do with the filters?
- 38:15And is there a risk for reinfection?
- 38:18We we don't know with certainty that
- 38:21there's zero risk for infection.
- 38:24So our suggestion was that there
- 38:26basically low-cost items to replace
- 38:28filters and tubing and so forth,
- 38:30so we recommended that once full
- 38:32recovery is taking place,
- 38:33that everything is is is is replaced,
- 38:36but the data on reinfection or right
- 38:38now seem to suggest there is not robust
- 38:41data that suggests that reinfection
- 38:43is possible is definitely happening,
- 38:45but we are also still relatively
- 38:47early in the pandemic,
- 38:48and as time goes on an immunity wanes.
- 38:51We may start to see some cases.
- 38:54It is clear though,
- 38:56that after two to three months,
- 38:58you romantic bodies do tend to wane,
- 39:00but it's thought that memory T
- 39:02cells still persist and offer some
- 39:04level of protection.
- 39:06In South Korea,
- 39:06there was a series of 284 cases
- 39:09that had a second positive test
- 39:11sometime within months two and
- 39:13three after symptom onset.
- 39:14However,
- 39:15in those patients they were not
- 39:17able to actually grow live virus
- 39:19from any of their registry isolates,
- 39:21and there was no transmission
- 39:23secondary transmission.
- 39:24Two 790 Contacts that were traced at
- 39:26this later time point and there were
- 39:28a subset of 23 patients who had serum
- 39:31drawn before and after the retest,
- 39:33and it turns out 96% of them
- 39:35still had antibodies.
- 39:36So at this point the evidence
- 39:38is not strong for reinfection.
- 39:41So I want to thank the COVID-19 Task Force.
- 39:43We've had an amazing group that
- 39:45works extremely hard and I thank
- 39:46you for your attention and I'm
- 39:48happy to take any questions.
- 40:03Do people need to be unmuted?
- 40:05Does anyone have their hand raised
- 40:07you so much for a wonderful talk?
- 40:09If anyone wants to put questions
- 40:11in the chat, you can do that.
- 40:13Or if you want to just unmute yourself
- 40:15so you can ask questions directly.
- 40:18Indira, please feel free to
- 40:20share what you were doing.
- 40:23If there's something you figured out,
- 40:26this is your chance.
- 40:28So from you.
- 40:29So Indira, the ASM
- 40:31looking at the the long haulers,
- 40:34the patients that have symptoms related
- 40:37to sleep that are just not going away.
- 40:41I I'm not talking about sleep apnea
- 40:44now I'm talking about patients who had
- 40:47Covid who continue to have symptoms
- 40:49of all sorts, many of which involve
- 40:52sleep. Yeah, I think that's a That
- 40:54is a great great point and I think
- 40:57it's one of the many areas where we
- 40:59need increased research activity.
- 41:01I believe there are groups that are
- 41:03tracking what's happening longitudinally
- 41:05with some of these kovid patients.
- 41:07I can't tell you who they are, but I.
- 41:09I mean, I know New York has
- 41:11had huge spikes in activities.
- 41:13There's probably a great cohort
- 41:15to follow there as well as some
- 41:17of the other cities that have
- 41:19had major spikes in activity,
- 41:20but I think that's a great point.
- 41:24You know the other aspect of this
- 41:26is that when you look at immunity
- 41:28and you look at this hyper immunity,
- 41:30the hyper immune reaction that
- 41:32people are talking about in the
- 41:35cases with severe COVID-19.
- 41:36You know, sleep is a major
- 41:38modulator of immune function,
- 41:39and so we really should be doing crossover
- 41:42studies between sleep and immunology.
- 41:43There are a lot of research questions that
- 41:46come up here that need to be addressed.
- 41:52But yeah, sleep disruption and what
- 41:55happens to sleep apnea with chronic lung
- 41:58damage and with the level of hypoxemia?
- 42:01Yeah, so send up needing oxygen, yeah,
- 42:03so there's one group of patients
- 42:06that I have seen have developed
- 42:08a fear of falling asleep.
- 42:10Who who don't actually have.
- 42:13A reason for it,
- 42:15they they just developed a fear.
- 42:17Falling asleep.
- 42:18Lot of patients have nightmares
- 42:21that they've never had before.
- 42:23And interesting, Lee enough.
- 42:25There's another group of people that
- 42:27I've encountered who are actually
- 42:29sleeping a lot more since Covid, Ann,
- 42:32and it's kind of interesting is that
- 42:35they say one of the reasons there
- 42:38kind of sleeping is to kill time.
- 42:41They're incredibly this,
- 42:42especially students.
- 42:43They're incredibly bored,
- 42:44and they wish that their life would,
- 42:47you know,
- 42:48go into Fast forward so they can get over
- 42:52this thing. Wow.
- 42:53So there's a lot of interesting
- 42:55stuff out there that we just don't
- 42:58know much about. Yes, I agree.
- 43:00And also with Tele work and what
- 43:02that's done with schedules and the
- 43:04opportunity for a later start in
- 43:06the morning has it actually helps
- 43:08some of our delayed sleep phasers
- 43:10have less misalignment and less a
- 43:11little bit less sleep deprivation.
- 43:13Yeah, there are a lot of
- 43:15really good questions.
- 43:16I've also heard about the possibility
- 43:18of Kleine Levin in some of our
- 43:20patients because of the, you know,
- 43:22any acute viral illness can
- 43:24precipitate that sleep disorder.
- 43:26So I think that you know the coming
- 43:28months and years we're going to
- 43:30be able to take a Fuller tally
- 43:32of the impact this has had on our
- 43:34population in terms of sleep health,
- 43:36yeah.
- 43:38For anyone interested in finding out
- 43:40more about the types of Covetous and
- 43:43which one is appropriate in your practice,
- 43:46we have a great talk.
- 43:48The ASM virtual sleep meeting
- 43:50happened at the end of August and
- 43:52Romy Hoque did a really wonderful
- 43:55synopsis of Cove in testing,
- 43:57so I would refer anyone who's
- 44:00interested to give it a listen.
- 44:03I'll just read out there's a question
- 44:05in the chat Endura from current
- 44:07Johnson at Bay State and she asks.
- 44:09She says we're testing patients
- 44:11prior to in lab testing for patients
- 44:13who have had kovid in the past.
- 44:15Since they may be positive
- 44:17for a long time on PCR,
- 44:19do you think that if they come in for
- 44:22a sleep study two weeks and symptom
- 44:24free later that they can be
- 44:26done without extra precautions?
- 44:27What about if they had kovid three
- 44:29or six months ago? Would you retest
- 44:32them at that point?
- 44:34Yeah, so thanks Karen.
- 44:36That's those are great questions.
- 44:37And yeah, I think the CDC
- 44:39changed their recommendation in
- 44:41originally with milder cases.
- 44:42There were two ways to determine
- 44:44when somebody had recovered.
- 44:46One was a test based strategy,
- 44:48which means you had two tests at
- 44:50least 24 hours apart before they
- 44:52can be deemed to be clear of virus
- 44:55and the other ways is if they were
- 44:58symptom free for 10 days and so you
- 45:00can you can use the symptom based
- 45:03strategy for the milder cases.
- 45:05For some of the people who
- 45:07have chronic illnesses,
- 45:08they can take longer to clear the virus
- 45:10and have persistent positive tests.
- 45:12It's hard to know if they have a
- 45:14positive test is a viral fragments or
- 45:16if they are sick with many comorbidities.
- 45:19Is it that it's lingering and that
- 45:21they potentially could be infectious?
- 45:23So I think those needs,
- 45:25and when is the window of time when
- 45:28someone clearly can be considered recovered.
- 45:30So these are all nebulous questions
- 45:32and we talked about it in our group.
- 45:35I would say consider an ID console.
- 45:38In fact,
- 45:38if you if you have a question and as
- 45:41far as antibodies response waiting,
- 45:44I think that it's thought that
- 45:46up to three months they may be.
- 45:50Protected,
- 45:50but once you start getting outside
- 45:52that six month window then we don't
- 45:55know and even within the three to six
- 45:57month window, we just don't know,
- 45:59but we haven't seen it,
- 46:01though we haven't seen a robust relapse
- 46:03rate or every infection rate rather,
- 46:05but relapse.
- 46:06It is possible if they never fully
- 46:08recovered the first time and they could
- 46:11still have the ability to relapse
- 46:13and potentially become infectious again.
- 46:15So yeah,
- 46:16I think will Carnes doing is pointing to.
- 46:19If someone tests positive,
- 46:21are they infected or infectious?
- 46:23And that's a really important distinction.
- 46:27And so antibody testing it's it's
- 46:30not thought to be fully useful.
- 46:34So it really is a clinical question
- 46:36and this is really for the patients
- 46:38who have moderate to severe
- 46:40disease and they are in a high
- 46:42risk group with many comorbidities.
- 46:43But the ones who are healthy have mild
- 46:46cases can be declared free once they are.
- 46:49Once they haven't had symptoms.
- 46:52Or 10 days or more.
- 46:55I
- 46:55classic question I see anywhere are
- 46:58you doing great talk? Thank you so
- 47:00much so question and observation.
- 47:02You know that study that you quoted
- 47:05regarding the covid virus still being
- 47:08on the various forms of materials and
- 47:11that's kind of what upset the basis for
- 47:13the three day recommendation that study.
- 47:16They didn't actually clean the
- 47:18materials after they re test it right?
- 47:20So that was that was just.
- 47:23So we're cleaning our studies.
- 47:25You know, so presumably there
- 47:27should be no no virus on there,
- 47:29but I don't think anyone is
- 47:30specifically studied that like I
- 47:32don't you know whether or not the
- 47:33cleaning how effective the cleaning is.
- 47:35I guess I sort of understand that,
- 47:37but that's sort of a little bit of
- 47:39something that's been an issue with
- 47:41us 'cause we want to get turned over.
- 47:43We had a big backlog of studies
- 47:45and we want to get them through
- 47:47in the three day recommendation.
- 47:48I kind of really slow things
- 47:50down a little bit and then just
- 47:52an interesting observation.
- 47:53I'm wondering if anyone has experienced
- 47:54this in their level Greece studies.
- 47:56We constantly cleaning these belts
- 47:58'cause the belts are really one and the
- 48:00device itself were not really reusable
- 48:02whereas we throw out the cannula.
- 48:03I could throughout the pulse ox
- 48:05but the belts have to be cleaned
- 48:07and as well as the device and our
- 48:09text to a lot of job in pushing the
- 48:12cleaning this stuff in the belts and
- 48:14we've noticed that we've actually
- 48:15lost a lot of the efforts.
- 48:17Signal the effort signals are not as
- 48:18good as they were before and we've
- 48:20gotten the machine was sort of fooled
- 48:22into thinking that there was central
- 48:24apnea when there really wasn't central
- 48:26apnea and and I'm just wondering if
- 48:28anyone has noticed that on there.
- 48:30On their home studies with the effort
- 48:31belts from the frequent cleaning
- 48:33could have an impact on the quality
- 48:35of the effort signal that we get
- 48:37from the machines in this morning.
- 48:38If that's been an observation for many one.
- 48:41Yeah, that's a great question.
- 48:43Would anyone like to respond in
- 48:45the chat or? Unmute yourself.
- 48:48We haven't seen that so far in OK,
- 48:52but it might also depend on if you own
- 48:55the devices versus if you rent them and
- 48:58and send them back and started after.
- 49:02Right, yeah, we we own the devices to
- 49:04work constantly turning him over as
- 49:06quickly as possible and so it's just
- 49:08I've had a few cases where, Oh my God,
- 49:11this looks like central apnea,
- 49:12but the patient does have any risk
- 49:14factors for central apnea and we
- 49:16really go over to finally tooth comb
- 49:18and I think it's not central apnea.
- 49:20I send them for diagnostic and
- 49:22it's all obstructive. No central.
- 49:23So the other thing to consider is patient
- 49:26education during setup and how many
- 49:28of them are not being rigorous with
- 49:30the positioning of the belt so that
- 49:32it's just a little bit misplaced, or.
- 49:35You know, because it can be really a
- 49:37function of of where on the Thorax,
- 49:39where on the abdomen, and sitting.
- 49:42Yeah, these are things that I think
- 49:44that it's going to take a lot of
- 49:46troubleshooting to figure out.
- 49:47Maybe try wearing it yourself, right?
- 49:49So so I will definitely let
- 49:51I'll give it three days before I put it
- 49:55on now, definitely. There
- 49:58are disposable belts that
- 49:59are available though. Yeah.
- 50:02Right, we looked into that.
- 50:03I think it was just an
- 50:05added of disposable costs.
- 50:07Reduces the bottom line.
- 50:08But yeah, I think that's
- 50:10something to consider. Very
- 50:12well, we're at the three o'clock hour,
- 50:14so I think we'll wrap up and I
- 50:16just want to let everybody know
- 50:18the information about the CME.
- 50:19Login is now in the chat.
- 50:21If you didn't see that early on,
- 50:23click on chat right now and you have
- 50:26until 3:15 to get CME credit for this.
- 50:28And please join us for next week.
- 50:30We have a talk by Lauren Hale
- 50:32from Stony Brook University.
- 50:33She's going to be speaking about racial
- 50:35disparities in sleep health and thank you
- 50:37everyone for joining today.
- 50:40Thank you, thank you.