The Day I Became A CSE
Stephen Eller, RPSGT, RST
I have been working in this field for 27 years, experiencing both day
and night shifts, year after year. In 2012, I attended the Clinical Sleep
Educator course that was sponsored by the BRPT in Reno, NV. This
two-day course had a profound effect on me as a technologist and
as a patient. It changed the whole game for me.
Since attending the CSE program, my mantra has been to listen three times more than I speak. Now, when I meet with patients, I let them get everything off their mind and simply listen-really listen. I then download their data card and look at things such as number of days with CPAP usage over 4 hours, and residual AHI, leak pressures, tidal volumes, rates etc. Next I evaluate the problem, address the interface and always review the patient's history for co-morbid factors. Following this process allows me to implement the basic principles of a CSE. I have been religious about listening, downloading, reviewing and evaluating. Using the techniques I learned during the CSE program has translated into improved patient outcomes in many of my patients in the CPAP Clinic. I have enjoyed explaining all the various treatments available for sleep apnea, and most certainly, the shocked looked on the patient's face when I explain about a tracheostomy in severe instances. Until recently, I really never felt like a CSE, just a tech with a certificate and above average education in this field. Becoming a CSE has made my work much more meaningful – and impactful.
A Clear Need
The following experience cemented in my mind the real and pressing need for Clinical Sleep Educators. I received a consult on a patient named John who had been non-adherent with CPAP for the last several months. I called the patient on a Friday afternoon and left a message for him to call me back for an appointment. When I walked in on Monday morning there were no messages from him. Before trying him again, I reviewed my new consults and there was John from Friday. However, he was now an in-patient in the ICU, with exacerbation of COPD. I received the consult because he refused to wear his CPAP the previous night in the ICU as the mask wasn't what he was accustomed to using.
I went to see my patient and to find out what was going on with him, why he wasn't using CPAP and to hear more about his objections and the barriers he was experiencing. I was determined to find a way to overcome those barriers. This was the perfect opportunity to use the new skills I had learned such as motivational interviewing and the "teach back" method. After reviewing his chart for history and co-morbid factors, I introduced myself to him and told him why I was standing at his bedside. I began simply by asking him why he didn't wear his CPAP last night. While he was talking, I was actually conducting an assessment of him. A 65 year old white male, barrel chest on O2 at 2 l/pm in obvious distress, on CPAP of 9cm H2O w/ 2 l/pm O2 entrained. He talked of how he can only wear CPAP for 2-3 hours per night. I asked if he had any issues with his interface, which he denied. I asked about any problems with the pressure which he described as "too much." I asked: Is that why you won't wear CPAP or are there any other issues you're experiencing? John said he only wears it a few hours because "my chest fills up with air and I can't breathe on it anymore." Bingo- he was trapping air on CPAP. I'll be right back I told him.
A few weeks earlier I remembered that a vendor came by to show off a new VPAP machine. The difference with this version, versus the many other versions of CPAP/VPAP machines, is that it has a shorter inspiratory time, allowing more time for patients with COPD to exhale.
As part of the intra-disciplinary team, I conferred with the Chief of Pulmonary Medicine and ran my idea past him. We agreed to this course of action which gave me the green light to use the demo unit and see how John would do. I then went back and explained to John what my plan was. I retrieved the unit, set it up for him to try, and brought him a new full-face mask to go with it. I also made the decision to change his therapy to VPAP-COPD at IPAP pressure of 10cm H2O and EPAP pressure of 5cm H2O. Rise time set at 150ms, Ti Max set at 1.0 sec and Ti Min 0.3 sec.
I gave John a trial of the VPAP and he felt very comfortable with it. He wore it for 15 minutes and showed no sign of air trapping. He even told me he was looking forward to going to bed that night. I assured him I would be back in the morning to check on him.
When I returned the next day, I saw a totally different patient! The first words out of his mouth were "I slept last night!" He told me he felt wonderful when he woke up, not the least bit tired and no desire to take his morning nap. John told me he woke just one time during the night. Later that day, John was moved to a step down unit.
The next morning I saw John, one more time, prior to being discharged later that day. He spent another restful night on his VPAP COPD. He did have one slight complaint though in that he still had difficulty exhaling. I made a slight adjustment in the settings and John was on his way home. Later that day I placed an order for our facilities first VPAP COPD machine. We have since ordered another unit for stock so that we can treat the next "John" that comes through the door!
This experience has taught me that I can play a role in re-admission rates by practicing the techniques I learned in Reno. After all, you never know when another consult will come through for a Clinical Sleep Educator.