North Carolina is no exception to other states that have grappled with the issues of licensure, exemptions, and declaratory rulings in the field of sleep technology. In 1999, North Carolina drafted HB 1340, a bill designed to regulate the practice of respiratory care. The bill was subsequently signed into law as the Respiratory Care Act on July 13, 2000. During the time for public comment, those involved with the bill realized that it had no provisions for other allied health care fields that provide limited respiratory care within their practice—and more specifically, for the field of sleep to practice polysomnography. Due to the foresight of several respiratory practitioners and polysomnographic technologists, the sleep community became involved in formulating a draft declaratory ruling to allow the field to function under this act.

Because of the respiratory-nature work that sleep professionals perform, an exemption to the bill had to be made in order for sleep clinicians to continue to legally practice. The job requirements of sleep that were within the respiratory care scope of practice were the application and titration of continuous positive airway pressure (CPAP) and bilevel therapy, application and titration of supplemental low-flow oxygen, application and monitoring of capnometry, application and monitoring of oximetry, and patient education on the application of the above for management of sleep disorders. Through the collaboration of the sleep and respiratory communities, a draft ruling, which provided a legal means to practice sleep-related testing under the respiratory care scope, was hammered out.

Under the ruling, registered polysomnographic technologists (RPSGTs) were deemed exempt from the Respiratory Care Act because of the knowledge they must demonstrate by passing the Board of Registered Polysomnographic Technologists (BRPT) competency examination.

According to the language of the ruling, the RPSGT falls under this exemption as “registered, certified, credentialed or licensed to engage in another profession or occupation in this State or must be working under the supervision of such a person.” Under this language, a means to provide sleep-related testing for those individuals that do not hold the RPSGT or respiratory care practitioner (RCP) credential also was provided.


Since its beginning stages, the declaratory ruling in NC has gone through several revisions. The most debated portion of the ruling involved the term “direct supervision.” Many sleep laboratories were against the idea of direct supervision, meaning that an RPSGT or an RCP must be in attendance during sleep studies. Defining direct supervision was very difficult, even for the respiratory care board. Many hospitals were using their respiratory departments as a form of supervision even though the RCPs had no working knowledge of sleep.

Those opposed to the ruling were afraid that the use of direct supervision would cause a shortage of beds or a large backlog of patients due to the lack of qualified individuals to supervise trainees in an already underserved profession. To solve the issue of supervision, the board had to define who needs to be supervised and who was performing sleep studies.

To generate such definitions, the North Carolina Respiratory Care Board (NCRCB) adopted the terms defined by the Association of Polysomnographic Technologists (APT) for technologists, technicians, and trainees. According to the APT, technologists are registered by the BRPT and hold the RPSGT credential. The RPSGT is the gold standard for those performing and supervising sleep studies. These individuals have been deemed qualified to meet the standards for safe and effective practice and are competent in the areas that overlap with the respiratory scope of practice. However, RPSGTs may not represent themselves as, or hold themselves out as, respiratory care practitioners.

Technicians have completed a polysomnographic program of no less than 1 year or have a minimum of 6 months of experience as a trainee, and have completed and documented the six required competencies and completed an approved positive airway pressure (PAP) course.

Trainees must be high school graduates with 6 months of experience in direct patient care, or have 1 year of postsecondary high school education, or are enrolled in an accredited polysomnographic program. Both technicians and trainees must follow a defined course of study that covers the knowledge and skills needed to pass the registry examination within the standard time frame of 24 months and 36 months, respectively.

Because of their degree of experience, both trainees and technicians must follow the supervision ruling set forth by the board. According to the declaratory ruling of October 2005, technicians that have proven competency can work under general supervision. General supervision is provided by an RPSGT or RCP. The RCP under this ruling must have proven competency in sleep-related testing, PAP titrations, low-flow oxygen, capnometry, oximetry, and sleep education. Those supervising must be available by phone or in person to provide consultation on sleep-related issues. The supervisor must be available to respond on-site if needed. Direct supervision also will be provided for sleep trainees. Under direct supervision, an RPSGT or competent RCP must be in the same sleep facility as the trainee. It is unacceptable for the supervisor to be available only by phone or to be performing other floor duties; the supervisor must be in attendance with the trainee.

To allay the fear of a lack of qualified personnel to perform sleep studies or a shortage of those providing supervision, the board attempted to develop a means to provide a pathway for trainees to move to a technician status. Providing this pathway would alleviate the need for direct supervision while still providing safe and effective care of patients in the sleep centers and laboratories. To do this, the sleep technology committee for the NCRCB is now providing sleep technology and PAP titration courses throughout the state. These classes will provide training and testing for the enumerated sleep-related practices that overlap with the respiratory scope of practice and will be a means of providing board-recognized competencies for technicians, trainees, and supervising RCPs. Despite the arrangement’s benefit of providing qualified personnel and supervision, the American Association for Respiratory Care (AARC) has expressed some concern over the ability of the NCRCB to enforce and monitor compliance with the ruling.


Many individuals practicing sleep, whether they are technologists, technicians, or trainees, often do not know about legislation in their own states. When HB 1340 was passed in North Carolina, there was no database of existing practitioners to inform them of the pending legislation. Therefore, information was not disseminated to those practicing in the sleep field. Hospital-based and freestanding facilities were virtually unaware of the changes taking place within their state and their profession.

Sleep laboratories based in hospitals were better informed once the resulting changes to the field of respiratory care started in 2001. Even after the declaratory ruling was passed, a vast majority of laboratories were in violation of the ruling, not from defiance, but from lack of knowledge. Today, the APT political action committee keeps a database of legislative changes on their Web site. They are continuously asking for updates from states, which is often from the grassroots level. In North Carolina, a sleep technology committee of the NCRCB watches out for the interests of the sleep community. Information is posted on the NCRCB Web site, along with information about upcoming meetings and the most recent rulings. It is up to the individual to access these sites and stay up-to-date with legislative changes to remain compliant. This must be the job of management as well as the responsibility of those practicing in the sleep field on a daily basis.


North Carolina sleep practitioners are currently looking at licensure. It would cost an estimated $20,000 to pass a sleep practice act in the state. This cost would be insurmountable considering the number of sleep professionals in the state that are currently practicing. Other factors that must be considered are finding support in the North Carolina General Assembly and the time it takes to pass a bill in the state.

To gain licensure, the sleep community is considering the help of the NCRCB. There would be a number of advantages to working with the NCRCB for licensure: passage of a licensure bill in the general assembly could be very quick since the NCRCB is already in place, and sleep technology would have immediate recognition as a profession in the state. On the other hand, an independent licensure board could prevent the respiratory care board from having a say in the practice of sleep medicine in North Carolina; however, an independent polysomnography practice act would necessitate an independent board to regulate sleep to protect patient health and safety.

The method of choice for licensure as expressed by the BRPT is to amend the state’s current respiratory care practice acts to exempt polysomnography under the direct supervision of a licensed physician. While the intent of the licensure bill is to exempt sleep practitioners, important questions arise once licensure occurs: (1) Who regulates an exempted occupation? (2) Where is the enforcement and monitoring of the profession? (3) How can you verify the proficiency and competency of the practitioner?

There are lessons to be learned from the experiences in North Carolina. Sleep professionals must be prepared to answer the questions and solve the issues that need to be dealt with in order to advance the practice of sleep technology throughout the United States. Sleep technology needs to be recognized as a profession and have the ability to govern their profession. To do this, professionals must organize, join their local and state sleep organizations, set up educational programs, and stay abreast of pending legislation in respiratory care, electroneurodiagnostics, and nursing. Practitioners also must band together in their states to form the numbers that are needed for licensure.

Lisa Johnson, RCP, RPSGT, MPH, is manager of Rex Sleep Disorders Center, Raleigh, NC. She can be reached at .