by Dave Shirazi, DDS, MS, MA, LAc, RPSGT, DABCP, DABC-DSM
Have you told a patient they need a PSG? Have you heard tales of fun and entertainment from your patients who’ve had one? Most physicians and dentists actually wince a little when referring a patient for an in lab sleep study (also known as a Polysomnogram) because they know the referral can be met with resistance, refusal, or unpleasant stories from the patient. We want the wealth of information that can be obtained from it, and our patients want us to help them without all that trouble.
As a dentist and registered sleep technologist, I’ve seen it from both sides; this essay is to give you insight into what happens to your patients so you can prepare them.
The first thing most patients think of is “I have to sleep where?” and “They’re going to be putting what all over my body?”, which then brings them to the next question, “Why do I have to do this?”. This is where educating the patient is so important, not just on the reason for the need, but also as to what’s going to happen.
The sleep lab can schedule the patient usually any night of the week, even if it needs to be a weekend, depending on how the lab is set up. All sleep labs have showers and bathrooms for those that need to go to work right after the study, more on why this is so, shortly. The sleep lab checks with the patient’s insurance to let them know of any fees, co-payments or deductibles; collections are usually the night of the test.
I tell the patient that the room is very similar to a hotel (if the sleep lab near you is ancient, you can say it’s more like a motel). Check in is one hour prior to their usual sleeping time. Each patient has their own room, and then the ‘fitting’ begins. This is where the sleep technologist, your own personal concierge for the evening, places sticky sensors, called ‘leads’ to capture EEG signals, EMG muscle activity of the masseters as well as the limbs, EKG signals, and air flow and O2 sensors. There are motion and sound detectors on the patient as well. The patient then completes their usual night time procedures such as using the restroom, reading a book, or watching TV, then attempts to go to sleep. All necessary medications need to be taken, though if a diuretic is typically used in the PM instead of the AM, I recommend that they switch that up, for obvious reasons. No alcohol or recreational drugs are permitted, no matter how common that is in their evening routine. Hypnotics are used only when absolutely necessary.
So that the best quality assessment can be made, during the sleep test the technologist is monitoring the data from each lead, reattaching any that come loose or pass bad data. They are there to assist if the patient needs to get up during the night. Some physicians leave a standing order to apply a PAP device if high levels of OSA are found; they will have a specific protocol for the technologist to follow. Sometimes, this is the patient’s first, last, and only experience with PAP therapy. Those are the patients who we hope get referred for OAT right away. If PAP is applied, the technologist adjusts the pressure until SDB is resolved and that pressure is noted in the chart, in all sleeping positions and stages of sleep, particularly REM.
In the morning the sleep technologist takes off the leads and asks the patient for a subjective assessment of the test; such as how the night went for them, how usual it felt, or if they got more or less sleep than any other night. This is where most want to shower to take off the conductive gel from the EEG leads and begin their day, going to work, home, or school directly from the lab. Another technologist will usually “score” the study a second time, checking latency to sleep and REM sleep, counting events, and developing indices, passing the scoring and the raw data to an MD or DO for interpretation and diagnosis.
I do spend a minute or two explaining all this to my patients, not least of which because I have my own sleep lab and I want them to have the most comfortable experience possible. I use very direct words such as ‘there are no blood tests that can give us the level of information and detail about you that one night of a sleep study can.’ For the stubborn (usually) male patient who still thinks they don’t have apnea, or that their wife is the person with the sleeping issues, I look over at their home sleep study or overnight pulse oximeter and mention ‘your oxygen dropped to 76%! You are doing this every night, and it is not our recommendation that you prolong this for even a moment longer’. People are stubborn in these cases when they are not fully informed. Facts are facts.
Lastly, I want everyone to know about the ‘do not do’ list. A dentist that is not an MD cannot interpret a sleep study, neither an HST nor a PSG; however they can inform the patient of what the sleep doctor has diagnosed. Sleep technologists cannot, by law, tell the patient what sleep problems the test shows them to have or pronounce them free from SDB. It’s good for you to reread that last line. They can point out things like ‘your oxygen dipped to__%’, but it must always follow with ‘you need to follow up with your referring doctor’. They cannot even say ‘I did not see any apnea’ either.
Oftentimes, because the sleep technologist cannot tell the patient what they have, if they do see apnea, they are usually told to immediately schedule the patient for a second study with CPAP. That means the patient was not informed of what they have, and they’ve been told to come back a second night, with PAP therapy. This can often lead to resentment and anger by the patient, or even non-compliance, because they have not been informed. We need to let them know that this is a common practice, and to not be alarmed by it. The dentist has the option to just let the patient have a titration CPAP study when they have mild to moderate, or ask the lab not to, if the patient has already proclaimed they will never wear a CPAP. On the other hand, if the patient has severe sleep apnea, they in effect, must have a follow up titration study.
I find when patients clearly understand why they are expected to undergo the sleep test, are well informed of the process and can name the problem that is being searched for and/or to be solved, the entire experience can be an effortless one. After all, they are spending most of the night with their eyes closed!
I encourage you to reach out to the sleep technologists in the sleep lab near you; everyone benefits from a better understanding of the role each professional plays. Every contribution is different but important; each carries the responsibility of educating the patient.