Classic SleepCast

Access to Sleep Care: Part II


Barry Krakow MD - February 27, 2019 - Expert Insight
Following on the last point from the first post in this series is the journalistic “malpractice” that offers up numerous sleep tips, often in the wrong context or simply in abbreviated fashion that would steer sleep disorders’ patients in the wrong direction. As I have described many times before, the concept of “sleep hygiene” is an inherently important construct, but it is often overstated in value, misunderstood conceptually, and repeated robotically by lay media, such that the message rarely gets across in a coherent, practical and useful way. My favorite example of this journalistic nonsense is the rote statements on going to bed every night at the same time…get this, as a treatment for insomnia! Do you really believe an insomniac wouldn’t love to go to bed every night at the exact same time as a simplistic and straightforward cure to the problem of unwanted sleeplessness? Of course they would,... Read more

Access to Sleep Care: Part I


Barry Krakow MD - February 17, 2019 - Expert Insight
The American Alliance for Health Sleep (AAHS) recently published their executive summary on their recent Access to Care Survey, specifically related to sleep. Although the number of participants was relatively small for this type of questionnaire, there were still some interesting critiques to be made about their efforts. In addition, I will also comment on some ideas for future surveys that might reveal a deeper understanding regarding the problems with access to sleep care. To start, the key conclusions of the AAHS Executive Summary involved those issues affecting an individual’s ability to access quality sleep, including: Cost of care and coverage by insurance companies Access to providers, both PCPs educated on sleep disorders as well as available sleep specialists Limitations of currently available treatments Access to accurate information online or from medical professionals They provided a few central recommendations, including improving: Access to sleep services for those suffering with sleep... Read more

OSA Facts & Pearls


Barry Krakow MD - February 05, 2019 - Expert Insight
Obstructive sleep apnea (OSA) is a serious medical disorder because of its direct impact on the brain and on the cardiovascular system. The direct damage caused by OSA stems from two highly disruptive factors seen in varying degrees in all patients suffering sleep-disordered breathing. The first and most obvious are the changes in oxygenation that emerge as either desaturations or as fluctuations. Desaturations are the most widely reported, because of the clear-cut damage from repetitively dropping oxygen levels below 90% (normal) and the going back and forth, that is, above and below 90% every minute or shorter. Fluctuations are more subtle where the oxygen baseline fluctuates all night, again going up and down while remaining above 90%. Yet, both these oxygenation problems have been linked in humans or animals to brain damage. The second factor, known as sleep fragmentation, is less widely reported and discussed, yet it probably has the... Read more

Managing PAP Compared to Managing Other Medical Interventions


Barry Krakow MD - February 01, 2019 - Expert Insight
One of the unique, if not peculiar aspects of managing patients on PAP therapy is that no standard model of medical care exactly matches our unusual and perceived as cumbersome or invasive treatment modality. Previously, we have talked about the common comparison of adjusting the dosage of a medication, as in the example of a diabetic or someone with depression who might need repeated medical visits, especially in the early stages of finding the right medication while concurrently fine tuning the dosage of the medication(s). Various steps often include the timing, the frequency of medication use, the amount of medicine, the variance of amount of medicine by time of day or other circumstances tailored to the individual patient, and of course the predictability of side-effects and how to take steps to prevent or overcome them. Such a process is usually called “medical management” of a disease process, and for the... Read more

Nasal Dilator Strips Update 2019: Part II


Barry Krakow MD - January 07, 2019 - Expert Insight
With such an array of opportunities to use NDS therapy and other conservative treatment approaches, one of the most important research areas for study would address how non-sleep, medical professionals recommend these steps to their patients. Regardless of how things shake out in sleep centers, more health professionals and especially primary care physicians, psychiatrists, and psychologists (not to mention assorted mental health therapists) are going to be asking virtually all their patients, “How are you sleeping?” Primary care physicians are probably the most pivotal group to study, because they experience directly or indirectly so much of the frustrations patients report in attempting PAP therapy. The complaints may consist of the specific difficulties in trying to use or adapt to PAP as well as complaints about dealing with sleep center or DME personnel, not to mention the ever present struggles with insurers that so often plague PAP patients. Imagine a study... Read more

Nasal Dilator Strip Update 2019: Part I


Barry Krakow MD - January 03, 2019 - Expert Insight
In 2015, we last discussed nasal strips (NDS) in depth to point out their wide applicability. With increasing experience, I would like to update a few aspects of this conservative yet effective treatment strategy, because I see certain trends indicating a larger growth potential than previously forecast. As briefly mentioned in a recent post, a close relative of mine used a nasal strip one night and was stunned by the dramatic improvement in sleep quality noted on his Fit-Bit. He was also intrigued by the notably enhanced sleep quality he experienced that night and was unequivocal about sleep being more refreshing and daytime energy levels being higher. However, this individual was not a treatment-seeking sleep disorder patient. Rather, his experimentation with NDS derived from a chance conversation at a family outing. Eventually, despite these apparent gains, the individual experienced no concomitant motivation to maintain regular use of NDS, though it... Read more

Do Health Insurance Companies Act Rationally? Part V


Barry Krakow MD - December 18, 2018 - Expert Insight
We last discussed chinstraps and the difficulties many patients may have in their attempts to consistently use them. Eventually, some of these patients must gain access to the sleep lab as they are unable to accurately manipulate the chinstrap into their mask system. As noted, even something as straightforward as wearing the chinstrap inside the mask (nontraditional) versus outside the mask frame (traditional fitting) may still require a trip to the sleep lab, if we can persuade certain insurance companies to grant the authorization for testing.  In the examples that follow, you may or may not be surprised to learn how finicky some insurers operate to block the process entirely or complicate things so much as to erase any further patient motivation to move forward. On the other hand, we continue to be impressed with Medicare’s stance that permits the sleep physician to make the final call on which patient... Read more
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