Tonight and every night, an estimated 18 million Americans will not get a good night’s sleep because they suffer from obstructive sleep apnea (OSA), a disordered breathing condition that can have consequences far more troubling than the snoring that often accompanies it.

OSA is associated with high blood pressure, congestive heart failure, irregular heartbeat, and increased risk of heart attack or stroke. It has been linked to diabetes, depression, epilepsy, and decreased quality of life caused by disrupted sleep patterns. Still, of the 18 million Americans believed to be affected by OSA, only 10% to 15% have been diagnosed, according to the University of California, San Francisco, a leading research institution in the field.

In fact, it was only in the mid 1980s that the medical community began to recognize OSA and develop treatments. Since then, doctor and patient awareness of the condition has grown, and treatments—involving noninvasive ventilation and continuous positive airway pressure—have proven to be highly successful. But with so many people still undiagnosed, there is a long way to go.

Home Respiratory Care (HRC), Sleep Solution is playing its part in that national journey toward better OSA awareness, diagnosis, and treatment. Founded in 1995 by Diana Guth, a respiratory therapist with 3 decades of experience, Los Angeles-based HRC specializes in home respiratory therapy with particular emphasis on equipment and OSA care.

Breathing In
“I was in on the ground floor and saw the evolution of sleep apnea,” says Guth, who worked for 7 years at a major HME provider in the area, helping to build its business in the then-emerging field. “I found it fascinating, and I learned everything I could about it.”

Guth’s dedication earned her a good reputation among vendors, sleep laboratories, and physicians in the local medical community. When the HME dealer she worked for experienced difficult financial problems, she left and soon after a vendor encouraged her to start her own business focused on sleep apnea.

“I liked the idea of being able to treat the patients in the manner I saw fit, but I started on nothing,” Guth recalls. “I made three phone calls to the laboratories that I had worked with, and they were so glad I was back. They started sending patients, and that put me in business immediately.”

HRC quickly outgrew its first home—a 400-square-foot office on the west side of Los Angeles—and moved three doors down into its current 1,400-square-foot office. But even with success, Guth has been able to maintain a lean operation that includes two other therapists and three office support staff.

“I run the business more like a medical practice,” Guth says. “It’s all respiratory and I don’t have any other DME. We have a waiting room, and two sitting rooms with beds. It is homey here; it is a very upbeat place for the patients to come in a good neighborhood.”

One therapist, Glen Noble, has worked with Guth for 4 years and helped build the business; the other, Brad Erickson, used to call on HRC as a manufacturer’s sales representative and has improved its marketing efforts since joining the company about a year ago.

“Our referrals primarily come from sleep laboratories and individual physicians, and they can’t send us patients if they don’t know we’re here,” Guth says. “That was an area where I was weak. Brad and I were seeing patients and it was very difficult to divide my time anymore, so I needed someone to help with that part of the business.”

Fit and Follow
HRC offers a wide selection of masks and machines for sleep apnea treatment. “The key to success is proper fit of the mask, so we have a huge variety of interfaces; we probably have every interface known to man,” Guth says. “We let the patient try on a few different masks—sometimes quite a few. We have beds so they can lie down to see what it’s like in a position that they typically sleep in.”

HRC’s customer base is as diverse as its inventory, with patients aged 20 to 90, although the most common profile is an older, overweight male. The patients arrive at HRC with a range of attitudes, Guth says. “Some are reluctant or apprehensive; however, once they get a sample of a good night’s sleep, they want to be set up right away.”

As for patient comfort, almost all the machines have a feature called a ramp or delay whereby the patient presses a button and starts the unit at a low pressure—4 centimeters of water for 10 to 30 minutes. As they fall asleep, the machine automatically raises the pressure.

Equipment variety is only one area where HRC distinguishes itself from other practitioners in the sleep apnea field. Equally important is the initial interaction with the patients and the ongoing follow-up after they take the equipment home.

“You need to pay attention to all kinds of details,” Guth explains. “Before we do anything, we interview the patients to find out why they sought help, how they feel about it, if they’re claustrophobic or have sinus problems. As we’re speaking to the patients, we’re actually studying them to see what kind of mask or interface will best fit.”

HRC’s follow-up with patients starts within 72 hours after they leave the office and includes extensive clinical notes, Guth says. “The first few days are critical. Then we follow up a week later and a month after that. Some people take to it like ducks to water; other people require a lot more attention. We might have to change a mask or add humidification, or we may need to call a doctor to change the pressure or setup.

“We follow up until the patient is compliant and comfortable, or we’ve uncovered all the stones we can and they just can’t acclimate for one reason or another.”

With an unusually high 95% compliance rate, HRC usually finds a solution. Guth does not claim any special secret, just a steadfast focus.

“The other companies that do what we do are part of bigger companies,” Guth says. “They use other DME, so sleep apnea is only one aspect of their business, and for the most part, they can’t offer the total professionalism that we do.”

Breathing Out
Sleep apnea sufferers make up most of HRC’s business, but the company has been able to extend its respiratory expertise to help patients with other conditions. HRC now provides noninvasive ventilation to people with muscular disorders—patients who have amyotrophic lateral sclerosis and postpolio syndrome, who are at great risk of complete respiratory failure.

“The machines they use are different, but the way they are attached is the same; it’s a process called noninvasive positive pressure ventilation,” Guth says. “It keeps them out of trouble. They frequently use different masks, which are usually full-faced.”

For these patients, HRC does make house calls. “They’re not ambulatory, so we go to their homes. The follow-up is longer; however, the rewards are the same, if not greater. They really are special people,” Guth says. “We get excellent results treating the patients, especially when we do a good follow-up. It’s a mechanical approach to a serious problem that really works. It makes a profound difference in their lives—they really feel better and it’s nice to be able to help.”

Guth still refers to herself as a clinician who happened to start a business and she wants others to share her success. In the process, she wants to contribute by helping the millions of undiagnosed sleep apnea sufferers as awareness continues to grow.

“The medical community is recognizing sleep apnea more and the situation has gotten much better, but disorders are still underdiagnosed,” she says. “Patients are not being treated the way they need to be, and that’s a concern. I would like to be able to share what has been successful for me with other people around the country.”

Aaron R. Smith is a contributing writer for Dealer/Provider.

Respiratory Insider

John Hupp Respiratory care telemetry has been the subject of much recent attention among liquid oxygen users. John Hupp, president of CoolTel, a division of Chart Industries, Burnsville, Minn, shares with Dealer/Provider how its system can benefit HME providers. Q What makes the O2Guardian™ special? A O2Guardian gives dealers a powerful new capability that will revolutionize their LOX delivery method and dramatically increase their profit. It is the first telemetry service specifically focused on the liquid oxygen HME dealer market and the first to combine the information on reservoir levels with a sophisticated logistics planning and routing solution. The system enables the HME dealer to fill their patients’ liquid reservoirs just-in-time, and to schedule these deliveries efficiently. O2Guardian is the only system that allows the HME dealer to move from inefficient static routing to optimized, dynamic routing. Another unique feature is that the O2Guardian works with reservoirs from any manufacturer. Because our customers frequently deliver other products in addition to liquid oxygen, the routing and logistics package is designed to optimize the total delivery process for all liquids and nonliquids. Q What are the advantages of the O2Guardian for HME suppliers? A Today, HME suppliers are making far more liquid deliveries than necessary. Many of the reservoirs are more than half full at the time of delivery. With O2Guardian, dealers make far fewer deliveries while making sure that customers never run out. For the dealer, this means fewer miles, fewer labor hours, and more profit. The same number of trucks can, with the O2Guardian, handle up to twice the number of liquid patients. There is no way to deliver liquid oxygen more efficiently. Dealers are looking for ways to keep their liquid deliveries to no more than once per month. Our customers are experiencing dramatic reductions in the number of visits necessary to keep their patients in liquid oxygen. Deliveries to patients on a low-loss reservoir and concentrator, for example, are pushing out past 40 days on average. Before telemetry, these were 21-day static deliveries. One advantage of using the O2Guardian that we did not thoroughly appreciate when we started was how the new information would enable our dealers to better understand and manage their businesses. The information has driven them to higher levels of productivity. For example, by efficiently tracking patient usage rates, our customers have been able to more appropriately size the reservoirs. By knowing where and how much oxygen will be delivered each day, dealers can finely tune truck and driver utilization. Q What do you foresee for the future of the respiratory industry? A The market is decidedly moving toward therapies that allow for greater patient mobility. Some HME dealers have been reluctant to offer liquid oxygen because they perceive it to be more expensive than concentrators and high-pressure cylinders. With the efficiencies gained with the O2Guardian telemetry system, depending on the ambulatory needs of the patient, a concentrator and liquid combination or a straight liquid system will likely be the best way to go. We expect liquid to gain market share as patients demand increased mobility and as the cost to provide it comes down.