RTs possess needed and unique skills when it comes to sleep studies, patient assessment, and equipment setup and operation

The investigation of sleep disorders is a rapidly growing area of medicine. The importance of good sleep health has been recognized and focused upon recently by network television news magazines, Congressional hearings, and health care researchers. While sleep medicine is going through a boom of recognition and advancements, the fundamental requirements for polysomnographers (sleep technicians) are only now being better defined, and are not codified into law. Therefore, some sleep laboratories or centers use college students who are trained on the job and perform the studies as a way to make some money while in school. Some use nurses and electroencephalography (EEG) technologists, and/or others use respiratory therapists. There is no stipulation as to the “best” or “preferred” background for a prospective polysomnography (PSG) technologist, and no requirement for any prior medical background. A PSG technologist could be—and often is—a person with no prior medical background.

The American Academy of Sleep Medicine (AASM)—formerly the American Sleep Disorders Association—stipulates the knowledge and training required for technologists who perform polysomnography. It states1 that the person performing a sleep study must:

• be thoroughly familiar with all instrumentation used in a sleep laboratory and have a command of the sleep-induced changes in the physiology of various body systems including, but not limited to, the neurological, musculoskeletal, cardiac, and respiratory systems;
• have a working knowledge of the physiological and behavioral aberrations associated with sleep/arousal pathology; and
• be capable of rapid interpretation of electroencephalographic, electro-oculographic, electromyographic, electrocardiographic, and respiratory tracings so as to be able to intervene appropriately during a study.

The AASM further stipulates1 that specialized training of a PSG technologist includes instruction in:

• using specialized instruments to record (during sleep) electrical potentials from the brain (electroencephalography), eyes (electro-oculography), and skeletal muscle (electromyography);
• using specialized instruments to measure and record (during sleep) other physiological parameters including nasal and oral airflow, thoracic and abdominal respiratory effort, electrocardiography, oximetry, snoring, esophageal pressure, and esophageal pH;
• online monitoring and analysis of PSG recordings, including preparation of detailed reports of sleep architecture, cardiac, respiratory, and other physiologic events recorded through the night;
• integrating polysomnography and continuous positive airway pressure (CPAP) equipment to titrate CPAP against respiratory events and arousals;
• recognizing and appropriately responding to critical events that can occur in sleep, such as cardiac arrhythmias, seizure disorders, and other medical emergencies; and
• interacting with patients to assure they are comfortable and providing patient education on sleep/arousal disorders (including obstructive sleep apneas) and CPAP.

So, does the respiratory therapist have a reasonable role in sleep medicine, and if so, what is it?

Testing
An evaluation of the previously listed requirements makes it clear that respiratory therapists, while not fully prepared to perform polysomnography without some additional training, are excellent candidates for the role of PSG technologist. Respiratory therapists receive extensive training in the use and interpretation of graphic displays, and the correlation of these displays to physiological conditions. Additionally, respiratory therapists, by virtue of their attraction to the profession of respiratory care, are comfortable with high technology equipment. They are generally able to quickly understand and adapt to the technology and the information it provides. Respiratory therapists receive more thorough and complete training in the anatomy, physiology, and mechanics of ventilation and its associated disorders than any other allied health professionals. They are trained in the use, assessment, and trouble-shooting of pulse oximeters, as well as the finer points of oxygenation. This prepares them well for understanding the subtleties of the various changes potentially displayed during polysomnography. They are certainly prepared to apply and titrate CPAP, and they are also well prepared to handle various medical emergencies that might arise during a study.

Most respiratory therapists do not receive training in electroencephalography in their respiratory care curricula, but many receive postgraduate training in this technology. If a therapist is so trained, it is difficult to identify an allied health professional better prepared to be trained to perform polysomnography than a respiratory therapist.

Even with this strong background, a respiratory therapist is not fully prepared to undertake polysomnography without additional training that blends all of the component technologies and concepts into a package of knowledge that specifically incorporates application to sleep testing. Most local sleep laboratories or centers do not have the resources or the teaching expertise to provide such training in-house. It is therefore best for most facilities to seek professionally provided external training for new PSG technologists. With appropriate sleep training, respiratory therapists can and are performing exceptionally well in performing, monitoring, and scoring polysomnography.

Treatment
The most common treatment for the most common sleep disorder, sleep apnea, is CPAP. Another treatment for sleep disorders is nocturnal oxygen therapy to preclude against documented deoxygenation during sleep. These are both areas of expertise for respiratory therapists, and are included, specifically or within a category of services, in the respiratory therapy scope of practice in all states in which respiratory therapy is licensed, certified, or otherwise recognized and regulated by the government. The fact that these procedures fall squarely in the scope of practice of respiratory care, and that PSG technologists are not members of a licensed profession, has led to a bit of controversy.

The least expensive and best prepared professionals in these procedures are respiratory therapists. It is therefore reasonable that respiratory therapists be deeply involved in the treatment of sleep disorders, through the sleep laboratory, respiratory department, or physician’s office, or as a member of the staff at durable medical equipment (DME) companies. Most states’ licensure or certification laws for respiratory therapy require that RTs or other licensed personnel, whose scope of practice includes these procedures, perform them.

Respiratory therapists understand the discomfort and fear that applying CPAP can cause and are well prepared to coach and train difficult patients to use their devices properly and to comply with the plan of treatment. More important, they have a thorough understanding of the potential untoward outcomes of the use of CPAP, including potential decrease of cardiac output. Such an impact might not occur in the sleep laboratory but manifest itself over the course of treatment, perhaps if the patient becomes hypovolemic. It is important that the person monitoring this care be aware of and watchful for not just initial responses to therapy, but dynamic responses that change with patient condition. This again points to the respiratory therapist.

Unfortunately, Health Care Financing Administration (HCFA) policy precludes separate reimbursement to DME companies for the services of a respiratory therapist. This provides a financial incentive to use drivers or other unlicensed/untrained personnel to deliver and set up equipment, and teach about CPAP and oxygen. But the various state licensure boards are beginning to address this issue aggressively.

Education
Respiratory therapists have long functioned as educators and coaches in the hospital setting, and they are functioning in that role in sleep medicine as well. This begins with education of the patient during sleep studies and CPAP titration. With their knowledge of anatomy and physiology, respiratory therapists have a world of information to share with sleep disorder patients. Their education role continues in preparing and coaching patients who require CPAP or oxygen therapy, and in explaining the risks of these procedures. Respiratory therapists also participate in the education of other PSG technologists, through in-services, training programs, conferences, and seminars.

Controversy and Challenges
The issue of licensure and its impact on the role of nonlicensed PSG technologists has recently become the focus of controversy. At issue is the practice of nonlicensed PSG technologists performing procedures that are clearly within the licensure scope of the practice of respiratory therapists. These include oxygen administration; CPAP initiation, monitoring, and instruction; and patient education. Several states have reached policy-based compromises on this issue, allowing PSG technologists to continue performing these procedures in conjunction with sleep testing:

According to the Association of Polysomnographic Technologists (APT), “Ohio and Washington have taken a more balanced approach to ensure patient care and allow trained polysomnographic technologists to continue in their profession. Those states require technologists to work under the supervision of a recognized sleep medicine specialist and/or to become credentialed as an RPSGT by passing the Comprehensive Registry Examination for Polysomnographic Technologists.”2

However, in February 1999, the New York State Board for Respiratory Therapy evaluated their state’s respiratory licensure act and determined that it requires respiratory therapists to perform several of the procedures historically performed by unlicensed PSG technologists. Under this decision, unless a PSG technologist is also a licensed respiratory therapist, the technologist is legally unable to perform significant parts of a sleep study. Specifically, the New York decision requires sleep laboratories to retain licensed respiratory therapists or technicians to perform:

• setting up/adjust oxygen;
• setting up and adjusting CPAP/bilevel positive airway pressure ventilation;
• educating patients and family;
• conducting cardiopulmonary rehabilitation;
• monitoring physiological parameters of patients; and
• verifying accuracy of health care professional’s prescriptions.

This interpretation greatly strengthens the role of respiratory therapists as PSG technologists, but it predictably angers the nonlicensed PSG technologists. The APT is working to effect a change in the law or this decision, in some cases reportedly seeking to have these procedures removed from respiratory therapy scope of practice. This would then leave unlicensed PSG technologists free to perform these procedures without violating licensure laws. Unfortunately, this would also leave everyone else free to do so, including truck drivers and delivery people. Since the purpose of licensure is to protect the patient, opening the door to this possiblity is not in keeping with the goals of licensure. Hopefully, this controversy will be resolved in a more positive and mutually beneficial manner.

Even as this issue seems to strengthen the role of respiratory therapists in sleep testing, a new rule for Medicare from HCFA may place new requirements on all individuals who perform polysomnography in an Independent Diagnostic Testing Facility (IDTF). This rule, which currently is implemented in Florida, requires that “nonphysician personnel demonstrate the basic qualifications to perform the test in question and have training and proficiency by licensure or certification by the appropriate state health or education department. In the absence of a state licensing board, the technician must be certified by an appropriate national credentialing body.”

The question, of course, is which national accrediting body is appropriate for credentialing for polysomnography. As of April 1999, it was clear that the RPSGT credential from the Board of Registered Polysomnographic Technologists (BRPT) is considered sufficient. But would an RRT or CRT from the National Board of Respiratory Care meet the requirement? This may “put the shoe on the other foot,” requiring respiratory therapists who perform polysomnography in a nonhospital setting to obtain the RPSGT credential. Since rules such as this one are adopted by the Medicare Financial Intermediaries on a state-by-state basis, the degree to which this rule will spread to other states is uncertain.

Conclusion
In reality, respiratory therapists are involved in sleep medicine in all of the roles described previously, either full-time or cross-trained. The facts presented here support this activity and the expansion of their sleep medicine involvement. Respiratory therapists possess needed and unique skills when it comes to sleep studies, patient instruction and education, patient assessment, and equipment setup and operation. Certainly, not all therapists have experience with the EEG portions of the polysomnogram, but they do have a thorough understanding of the anatomy and physiology of breathing and oxygenation, as well as a comfort level with technology not common to many other health care professionals. Further, they bring a unique blend of high tech and high touch to patient care. Such blending of these two diverse strengths is of great value in a one-to-one service such as sleep disorders testing and treatment.

Larry Conway, RRT, is director of respiratory, neurology, and sleep disorder services, North Mississippi Medical Center, Tupelo.

References
1. American Academy of Sleep Medicine. Position Paper—Role and Qualifications of Technologists Performing Polysomnography. April 1998. Available at: http://www.asda.org/PDF%20Files/Role%20and%20Qualifications.pdf. Accessed on September 11, 2000.

2. Association of Polysomnographic Technologists. Position on New York State Scope of Practice Issues Related to Polysomnography. Available at: http://www.aptweb.org/homepage/new/new15.htm. Accessed on September 11, 2000.