OSA vs. OSH - Clinical diagnosis practices

[derek]

As most of you know I was annoyed/upset a couple of days ago to be told that I was diagnosed with OSA when neither of two clinical studies showed any apneas at all. I am reposting a response from -SWS in another thread, because I think that it is very important, and may affect others as well:

Derek, my impression is that sleep medicine has always been at odds regarding the best way to diagnostically categorize hypopnea exclusive patients. I experienced almost exclusively hypopneas during my PSG, yet I was given the diagnosis of "obstructive sleep apnea". My impression is that this informal diagnostic protocol arose from the early days when insurance carriers were less likely to cover the cost of CPAP for hypopnea exclusive patients. In those early days, hypopnea exclusivity was not as empirically understood by the medical and insurance industries as apnea exclusivity was. For better or worse, most hypopnea exclusive patients come away from their PSG with an "apnea" diagnosis to this day. Some take home UARS or RERA diagnoses depending on their airway physiology and diagnostic circumstances.

In the last couple of years I have noticed my own distribution of sleep events to slowly manifest a slightly lower ratio of hypopneas to apneas. Maybe an "OSA" diagnosis for us "hypopnea hose heads" is but a self-fullfilling prophecy of sorts!

The bolding is mine. In these days of enlightenment I think that this situation (if true) is pretty bad. To be told that you have OSA, with all its concomitant problems, when in fact you have a lesser condition is simply not good medical practice.

Thanks again to -SWS for his response.
derek
---------
Hypopneacs of the world unite!

[Liam1965]

I still think that you're splitting hairs (and since I'm in basically the same camp, I feel qualified to comment). I consider myself to have POSA (Partial Obstructive Sleep Apnea). Yes, in technical terms "apnea" does refer to a complete cessation of breathing, but until receiving the diagnosis and coming to this site, I didn't realize that.

I thought apnea referred to ANY restriction of breathing. That my throat doesn't generally ENTIRELY close off, and my breathing doesn't ENTIRELY stop most times doesn't mean that I don't have many of the same issues that those with more severe forms of the disease have.

For example, skin cancers are apparently very common and (if caught at a reasonable stage) easily cured. At the other end of the scale, pancreatic cancer (which one of my co-workers' best friend currently has) is an almost certain death sentence, with (if I recall correctly) about a 5% survival rate after 5 years. Knowing this, it's quite scary to be given a diagnosis of "cancer", but I don't think it's reasonable to expect a doctor to use some other word.

Liam, who isn't trying to minimize your argument, just doesn't necessarily agree with it.

[derek]

Wil(Liam),
Can we disagree and still be friends - pretty please

I walk into my regular doc's office. He says "I have the report from the sleep lab. You have sleep apnea, which is a serious condition... blah, blah, blah ... oxygen desaturation ... long term health problems ... high blood pressure ... blah, blah, blah ... chance of sudden death ... Reggie White ... etc. We need to get you on CPAP asap"

as opposed to

"The report from the sleep lab indicates that during the night you have regular episodes of hypopneas, which are partial obstructions of the airway, and can lead to your sleep being interrupted during the night. The sleep lab feels that you may be helped with CPAP, and that you will feel much better in the morning if we can eliminate these episodes... The sleep lab would like you to go back for a second study in which they will determine just how CPAP will help you."

I basically got the first approach, because that's what the sleep lab told my doc. I don't blame him at all, he was just working with the info he got.

Liam my friend, which report would you rather get?

derek

[Liam1965]

OK, point taken. See, I thought your objection was to the term OSA for your (our) disorder. I got the "We're going to test you for apnea, and if we find it, here's some of what it can mean" scare speech BEFORE my sleep test, and afterwards I got "Well, you definitely have OSA, but the good news is that your oxygen saturation never dropped significantly. People don't die from this type of OSA, they just tend to be really really tired."

If I'd gotten your lecture, I think I'd be more concerned as well. To me, the part of your story which borders on malpractice is the unwarranted scare tactics.

And sure, we can still be friends. Seeing how many people on the "Anonymous Survey" thread seem to hate my guts, I need all the friends I can get.

Liam, kidding of course, it was most nice to see all the support he got in said thread.

[Liam1965]

And sure, we can still be friends.

Come to think of it, you're less than 2 hours drive from me. We should try to see if there's an AWAKE group around here, and see if we Northeasterners can whoop it up like the Chicagoans can, but with less emphasis on pronouncing our R's.

Liam, same disease as derek, b'gOSH.

(Yeah, you already used the joke. Best I could come up with.)

[-SWS]

To be told that you have OSA, with all its concomitant problems, when in fact you have a lesser condition is simply not good medical practice.

Derek, I totally agree that your doctor dropped the ball regarding how your diagnosis was presented. My own informal clinical diagnosis matched your second description, yet on paper I was diagnosed with OSA.

However, I did want to bring up the point of "severity" regarding these two conditions. For the most part, both conditions share the same concomitant problems. That is because both conditions share the same two physiological roots of all evils: 1) cortical arousals (A.K.A. "sleep disturbances") and 2) oxygen desaturation. The first can cause sleep deprivation (of restorative sleep stages) and the second can cause hypoxemic or cellular damage. Hypopnea patients can actually experience these two worse than apnea patients. Since different patients respond to physioloigical stressors differently (epidemiology), hypopnea patients can even experience items one and two above with less severity than apnea patients, yet suffer much greater severity regarding both symptoms and concomitant disorders.

It took me the better part of a year to work my way out of REM rebound! I still suffer residual cognitive damage that never did fully heal after receiving my diagnosis and a CPAP machine.

Even AHI as a meaningful severity indicator of Sleep Disordered Breathing (SDB) has been vehemently debated amongst the world's leading sleep researchers. One's untreated AHI or whether one experiences hypopneas versus apneas seldom maps neatly to severity. Apnea versus hypopnea diagnoses and AHI are but two elusive epidemiological rabbits in the forest of untreated sleep events in my opinion. If it wasn't for that imprecise AHI benchmark, however, there would be many similar earmarks between SDB and a typical "syndrome" with unknown etiology. I have read posts by so many hypopnea exclusive patients who unfortunately suffer worse than apnea exclusive patients with much higher untreated AHI numbers. Go figure!

[Mikesus]

Thats better than being told that you need to take care of it so it will stop your snoring...

Somewhere in the middle is probably the best approach, unfortunately a lot of doctors fail miserably on bedside manner...

[Dave Hargett]

Keep in mind that the AHI is the Apnea/Hypopnea Index. Because they both cause arousals and interrupt sleep, they add the events together when creating the AHI.

In my own case, I had 17 apneas and 65 hypopneas per hour, and I de-satted as low as 52% even though most of my events are partial airway closings. That was called severe sleep apnea. CPAP gets me down to 2 events per hour, so I'm quite happy to be "normal" at that level, because I do feel good.

There are people who prefer OSAHS (Obstructive Sleep Apnea Hypopnea Syndrome) to OSA (obstructive sleep apnea) in order to be more accurate.

But it is the generally accepted definition in the field to call the disorder "Sleep Apnea" whether the problem is only apneas, only hypopneas, or a mix.

Keep in mind the definitions, too, that they have to last 10 seconds or more. They don't bother to count (necessarily) arousals from events that last 7 seconds. But if that event wakes you up it can disturb your sleep as well.

Dave

[wading thru the muck!]

There are people who prefer OSAHS (Obstructive Sleep Apnea Hypopnea Syndrome) to OSA (obstructive sleep apnea) in order to be more accurate.

I prefer dereks "OSH b'GOSH"

When I'm out at a dinner party I'd much rather announce "I've got OSH b'GOSH" than to say I have Sleep Apnea.

Derek, I'm loving your scathing posts. Any time you can legitimately throw in a few Blah Blahs you know you're cook'in.