From the Editor by Jan Morgan
AARC to Comment on FDA Guidance on Medical Gas Administration
Sputum Bowl 2001
96 KIX/Folsom Children’s Zoo Back to School Health Screening
Nebraska Society to Host International Fellow
Oral Devices as Treatment in Obstructive Sleep Apnea
From the President by Jeff Gonzales
2002 NSRC BOARD OF DIRECTORS NOMINATIONS
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It hardly seems possible, but the last quarter of 2001 is fast approaching. As our president stated, there is so much to do within our profession and community. It seems you cannot go one day without hearing about issues that involve and affect respiratory care practitioners, physicians, nurses, or other healthcare clinicians. Some of this publicity is great, but other times it can be quite negative. Getting involved with the community and reaching out to our government leaders can help strengthen healthcare’s image and inform people about issues in respiratory care.
The highlight of 2001 was, of course, the NSRC State Meeting in Kearney, Nebraska. This year was quite successful with 323 people attending. The board would like to thank our past vice president Jenny Bush and her education committee for all of the hard work put towards planning and implementing this event. She truly did a fine job, as evidenced by the many positive comments from participants of the state meeting.
Lastly, the NSRC would like to thank all the attendees and vendors who participated in the scavenger hunt at the meeting. The scavenger hunt was a good way to get to know your vendors and they all appreciate you taking the time to talk with them. The attendees walked away with some very nice gifts and the NSRC appreciates the support and sponsorship by the participating vendors.
The Food and Drug Administration (FDA) has issued a public health advisory regarding the administration of medical gas. This guidance is intended to alert hospitals, nursing homes, and other health care facilities to the hazards of medical gas mix-ups. The AARC will be preparing and issuing comments on the document, which is called a Guidance Document, to lend AARC support for the action. That letter will be posted on the AARC web site once issued.
The guidance document was prepared by the FDA following patient deaths and injuries due to unqualified workers being asked to connect oxygen systems within health care institutions.
The Food and Drug Administration (FDA) has received reports during the past 4 years from hospitals and nursing homes involving 7 deaths and 15 injuries to patients who were thought to be receiving medical grade oxygen, but were receiving a different gas (e.g., nitrogen) that had been mistakenly connected to the oxygen supply system. The FDA guidance document makes recommendations that will help hospitals, nursing homes, and other health care facilities avoid the tragedies that result from medical gas mix-ups.
To read the text of the FDA’s Guidance Document, go to: www.fda.gov/cder/guidance/4341fnl.htm.
I also appreciated the opportunity to talk with many of you in Kearney. I will keep in mind many of your suggestions. The Board does indeed listen to your concerns and if you have questions as to why the NSRC does some of the things that we do, please contact any Board member or myself so that factual information can be given.
I can say with absolute certainty the next few months are going to go by rather quickly and issues that will affect each and every one of us are going to surface on both the local and national level. Many of these issues have been prioritized, including the first National COPD Awareness month to be held during October to coincide with Respiratory Care Week. Make plans to actively involve your community and hospital to make this event a success.
As I reflect on the time I have served the NSRC, I can honestly say that the sky is the limit, for those individuals that wish to work hard and dream. I must stress that it will take everyone if our profession and organization is to succeed and prosper, whether it be helping on a committee, writing letters to senators on profession impacting issues, or recruiting AARC members. We need everyone; students and seasoned therapists willing to help when asked.
As previously mentioned it is imperative that everyone commits to helping. If everyone does a little, the task(s) will not be overwhelming. Sadly, this becomes even more evident when you suddenly realize that many of the individuals that you could rely on are no longer here. Helen Sorenson, of Omaha is moving to Texas, where she has accepted a faculty position. As an instructor at Metropolitan Community College, she became familiar with and has helped educate many therapists in the state of Nebraska. A published author in the field of Respiratory Care, Helen has served as Sputum Bowl Coordinator, committee member, and guest presenter at the State Educational Meeting on numerous occasions. Shane Blake, past president, newsletter editor, and committee member is taking a position at the Cleveland Clinic. These people are doers and were always willing to help out, not just in Nebraska, but on the National level providing input, writing letters, and presenting. While I do not expect each and every one of us to emulate everything these individuals did, it should be a goal of ours to become involved. I challenge each of you to pick up the phone or e-mail me and ask, “What do you need?” or “How can I help?” I promise the task will not be overwhelming because we have many organized and knowledgeable people working for the well- being of the profession. I encourage you to start by taking a small step. Try and recruit one individual to join OUR professional organization, the AARC. After you have done that give me a call, we need your help. Can I count on you?
Sponsored by Tyco Healthcare, (formerly Mallinckrodt), three student teams and five teams from some of the state’s finest institutions vied for the opportunity to compete for the title of “Nebraska Sputum Bowl Champions”.
The event was competitive from the beginning as the eventual champions had to rally from an opening round loss through the losers bracket with several hard fought competitions. The team from BryanLGH Medical Center consisting of: Rob Dickhaut, RRT, Todd Klopfenstein, RRT, Jacob Gier-Craft, RRT, and Jeff Gonzalez, RRT rallied to victory over their East Campus counterparts, Jill Sand, RRT, Shane Blake, RRT, Jake Ostrowsky, CRT, and Heidi Dostal, RRT.
The victory allows the team to advance to the national competition in San Antonio, TX, a trip that is being eagerly looked forward to by the members of the winning team. Their goal is to improve on the fourth place finish they achieved in Cinncinatti, Ohio last year.
This year’s event was well organized thanks in part to Helen Sorenson, RRT. Sadly, Helen accepted a faculty position in Texas and due to an employment commitment she was unable to be present at the state meeting. Her replacement, Charlotte Pasco, RRT did a fine job in conducting a well-run competition.
The event capped off a great first day of the conference, which included a wonderful dinner of prime rib with all of the trimmings and an educational seminar sponsored by Jerry Fast of Glaxo Wellcome. The evening’s entertainment featured a performance by renowned comedienne T. Marni Voss for the captive audience. The educational seminar promised and delivered something for everyone.
The Lincoln FM Station 96 KIX and the Folsom Children’s Zoo hosted its second annual Children’s health-screening day on August 18, 2001. Multiple health organizations were on hand to provide not only health screening but also to distribute health related information. The several hundred children and parents that were in attendance were treated to clowns, activities and to those individuals that visited each and every booth-free train rides around the zoo.
The Nebraska Society for Respiratory Care was on hand to educate and answer questions about asthma as well as dramatically illustrate the hazards of both cigarette smoking and smokeless tobacco. All that visited the NSRC booth liked the visual samples of the preserved, diseased lung and the “Mr. Gross Mouth” model. Individuals not familiar with this educational tool should be aware it is not for the squeamish as tobacco juice can appear at any time when little kids poke, prod and ask questions related to smokeless tobacco. One mother said, “While it is somewhat shocking, these demonstrations leave a lasting impression on children.”
At the completion of the five-hour event, the health fair was deemed a success by its organizers and participants and the decision to host the event next year were made.
A number of NSRC members assisted with the event, including members of Southeast Community College’s Respiratory Care Program. Also assisting with the NSRC booth were members of Southeast High School Citizenship Issues Class, whose members passed out both stickers and literature.
The NSRC wishes to sincerely thank all that participated in this very worthwhile community service as well as BryanLGH Medical Center that provided the equipment and handouts for the occasion.
Approximately 3% of the middle-aged population suffer from excessive daytime sleepiness, which is the result of frequent nighttime sleep interruptions caused by upper airway sleep disorders [7]. The most common upper airway disorder is obstructive sleep apnea or OSA.
OSA occurs in 2 to 4 % of the adult working –age population defined by an apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) of greater than five events per hour [7]. AHI is the total number of apneic and hypopneic events per hour of sleep. An apneic episode or apnea results from complete obstruction and cessation of breathing for at least 10 seconds. A hypopnea results from a partial obstruction and is a 50% reduction of airflow for 10 seconds or longer. Both are accompanied by a fall in blood oxygen saturation and/or a change in sleep to a lighter stage [7]. OSA is caused by a partial or complete obstruction of the upper airway despite respiratory muscles making an attempt to breath during sleep.
Individuals with OSA have an increased susceptibility to cardiovascular complications such as hypertension, cardiac arrhythmias, stroke, and myocardial infarction. In addition, individuals are susceptible to hypoxic complications caused by the decreased arterial oxygen saturation after an obstructive event. Hypoxia resulting from apnea may lead to medical conditions including bradycardia, tachycardia, systemic hypertension, pulmonary hypertension, and acute pulmonary edema [7].
The most common symptom of OSA is excessive daytime sleepiness. Impairment of alertness can make one susceptible to work or driving accidents, decreased social functioning, and poor work performance [10]. OSA patients tend to share common characteristics. Characteristics of OSA patients include middle-aged or older, obese, male, smoker, alcohol and/or sedative use [7].
The most common treatment for OSA is continuous positive airway pressure (CPAP). CPAP has been shown to decrease the apnea-hypopnea index and improve the overall quality of sleep in patients with upper airway sleep disorders. CPAP works by splinting the pharyngeal airway open and preventing soft tissue collapse during sleep. In a study done by D’Ambrosi, et al [9], twenty-nine individuals with severe OSA defined by a RDI of 77 (+ or – 9) events per hour showed great improvement. The RDI decreased from 77 (+ or – 9) to 4 (+ or – 6) events per hour and the arterial oxygen saturation during sleep increased from 79.0 (+ or – 2.1%) to 91.6 (+ or – 0.8%). In addition, patients reported a significant improvement in vitality, social functioning, and mental health.
Although CPAP is an effective treatment, there tends to be poor compliance on the part of patients. Reasons for poor compliance include but are not limited to skin abrasions, leaks, conjunctivitis, sinus irritation, claustrophobia, and limitations of sleeping position. According to Kline et al [1], 20% of patients abandon therapy within the first three months. Of those who resume treatment, many will only wear CPAP a few hours a night. It has been reported that only 55% use CPAP on a nightly basis of approximately 5 hours [7].
Because poor compliance compromises CPAP effectiveness, oral appliances have become an important treatment alternative for OSA. Oral devices are inserted in the mouth each night in an attempt to treat OSA. Oral appliances have two mechanisms of action. Oral devices increase upper airway space by moving the tongue and hyoid bone anteriorly as found in a 1998 study by Battegel et al in the European Journal of Orthodontics and cited by Ivanhoe et al [7]. In addition, in the Journal of Prosthetic Dentistry, Yoshida found that oral devices activate the masticatory and tongue muscles thereby preventing upper airway collapse as cited by Ivanhoe et al [7].
An example of an oral device is the mandibular positioning or advancement device. A mandibular advancement device or MAD may be fixed or adjustable. With a fixed MAD, the clinician determines the necessary mandibular advancement and the mandible is maintained in that position by the device. With an adjustable MAD, the mandible is advanced over a period until satisfactory results are achieved. Mandibular advancement devices have been shown to decrease the AHI in patients with OSA and in instances, increased the oxygen saturation. In a study done by Henke et al [6], 68% of the subjects had at least a 50% reduction in AHI with the advancement device. Of the twenty-eight subjects studied, twelve had an AHI of <15 events per hour and nine had <10 events per hour. Pellanda et al [4], also determined that mandibular devices improved AHI. Of fifteen subjects studied, the median AHI decreased from 36.25 events per hour to 5.5 events per hour. Pellanda et al also documented that the median oxygen saturation improved from 73% to 88% in 14 of 15 patients.
As with any treatment, there are side effects associated with MAD use. Two of the most frequently reported side effects include tooth and jaw muscle pain. Despite side effects, compliance remains adequate with MAD use and a MAD is better tolerated than CPAP. In a crossover study done by Clark et al [3], comparing CPAP with a MAD, it was determined that 17 of the 23 subjects were using the MAD nightly, 2 intermittently, and only 1 subject chose to wear the CPAP. In another study done by Clark et al [3], 60% of patients were still using the MAD at one year.
Because of the difference in design of numerous oral devices on the market, price varies. According to a mail survey of dentists who provide oral appliances, the total bill may range anywhere from $400-$2450 as found by Loube and published in Chest, 1997, and cited by Ayas et al [8].
Other treatment options for OSA are available, but will not be addressed in detail in this article. Behavioral changes such as weight loss, changing of sleep position, head posture, smoking cessation, and avoidance of central nervous system depressants may be beneficial for some individuals. In addition, surgical intervention is another treatment alternative for OSA.
CPAP is the most frequently prescribed treatment for individuals with OSA. Oral devices have been shown to be a successful alternative for those individuals who do not respond, are intolerant, or refuse treatment with CPAP. Every individual is different and as medical professionals, it is our responsibility to find the treatment that best fits the patients we serve so that they have an improved quality of life.
References
Kline LR, Phillips CJ. The vestibular in-line pressure system; Oral delivery of continuous positive airway pressure. Sleep 2000;23:A258-59.
Machado MC, Carvalho LC, Francisco S, Atallah AN, Prado GF, Silva AB. Quality of life in sleep apnea patients using intraoral mandibular
repositioner. Sleep 2000;23:A271.
Clark GT, Sohn JW, Hong CN. Treating obstructive sleep apnea and snoring:Assessment of an anterior mandibular positioning device. J
Am Dent Assoc 2000;131:765-71.
Pellanda A, Despland A, Pasche P. The anterior mandibular positioning device for the treatment of obstructive sleep apnea syndrome:
Experience with the Serenox. Clin Otolaryngol 1999;24:134-41.
Clark GT, Blumenfeld I, Yoffe N, Peled E, Lavie P. A crossover study comparing the efficacy of continuous positive airway pressure with
anterior mandibular positioning devices on patients with obstructive sleep apnea. Chest 1996;109:1477-83.
Henke KG, Frantz DE, Kuna ST. An oral mandibular advancement device for obstructive sleep apnea. Am J Respir Crit Care Med
2000;161:420-25.
Ivanhoe JR, Cibirka RM, Lefebvre CA, Parr GR. Dental considerations in upper airway sleep disorders: a review of the literature. J Prosthet
Dent 1999;82:685-98.
Ayas NT, Epstein LJ. Oral appliances in the treatment of obstructive sleep apnea and snoring. Curr Opin Pulm Med 1998;4:355-60.
D’Ambrosio C, Bowmwn T, Mohsenin V. Quality of life in patients with obstructive sleep apnea; Effect of nasal continuous positive airway
pressure. Chest 1999;115:123-29.
Hudgel D. Treatment of obstructive sleep apnea. Chest 1996;109:1346-58.
The NSRC is seeking applications for nominations for positions on the NSRC Board of Directors for the terms of office to begin after the 2002 annual meeting. This is a terrific opportunity to serve your state society and your profession. Applicants must be active AARC members as defined by the AARC Bylaws. Elected officers must meet the following requirements:
Maintain active membership in the AARC
Attend all annual NSRC State Educational Meetings
Attend quarterly board meetings
Fulfill position duties and term of office
Fulfill committee assignments as necessary for management of the NSRC
Offices available for 2002 are President Elect, Vice President, Secretary, Alternate Delegate, and Director from the Lincoln area. Nominations close October 31, 2001. Please contact any member of the Nominations Committee for more details or an application form. Application and information are also available on the NSRC website.
Nominations committee work phone numbers:
Tom Bainbridge 308-535-7365
Patty Bauer 402-354-3245
Connie Nelson 402-420-7744
Lil O’Neill 402-481-8026
Jerry Turman 402-481-5348
Sue Waggoner 402-559-8554
Kathy Lynn Weaver 308-697-3329
Mike Stoakes 402-434-2985