Final Report - sort of

[TooNew]

Well, the final report is in the hands of the doctors but not my hands - I have to go get a copy.

They did tell me I just have mild OSA - if that's true, why do I feel so lousy? I'm a stomach sleeper so they probably never got a back reading - could that be even worse?

Does mild OSA really need CPAP?

Thanks,

[TASmart]

Depends on how disrupted your sleep is, and what the study shows. The classification are statistic and somewhat arbitrary. Need for treatment depends on AHI, O2 desaturation, and sleep disturbance.

[Pugsy]

The medical community uses AHI for the "classification" of severity and sometimes there's just more to it than the AHI.

And yes, it is very possible that the OSA is worse when supine sleeping and also worse in REM sleep.

Mild is up to 15 AHI....that's once every 4 minutes in an hour. How about I come over to your house and poke you with a stick once every 4 minutes and wake you up all night long...see how good you feel.

In reality it doesn't always work out to once every 4 minutes. Most of the time there will be some times with not much going on and other times with a lot going on. The AHI is just an hourly average over the entire sleep night...some hours could be more and some could be less.
There's a good example in this thread
viewtopic.php?f=1&t=155913&start=30
with this report where the AHI is 10 but some very dense clustering.
http://imgur.com/a/3ncuv

Oxygen levels aren't taken into account with the severity classification...neither is event duration.
A person can have bad drops in oxygen from just a few apnea events if those events are prolonged.
So there's simply more to it than just AHI.

[TooNew]

OK, that confirms my thoughts. I will be knocking on the records office door this afternoon - I want MY report in MY hands today.

[Pugsy]

actually stick poking is far worse

Not necessarily. For all we know he could have an AHI of 12 with desats to the low 70s because the events were prolonged.
I had that happen to me... and in REM sleep it got even worse...much worse which earned me the "severe" category with over 50 per hour. Just imagine what my O2 was doing then.

I think I would take a pokey stick over desats to 70% any day of the week.

[robysue]

The severity of the apnea (in terms of the AHI) is not always reflected in the severity of the symptoms.

My diagnostic AHI was around 23, but I never had the daytime sleepies issues so many people have. My husband's diagnostic AHI was around 10, and he was falling asleep during the daytime and evening with alarming frequency. Neither of us had any issues with O2 desats noted on the diagnostic sleep studies.

Near as we can tell, my body had developed ways to cope with the nightly interruptions from the OSA and let me function during the daytime and my husband's body hadn't.

Finally for what it's worth, I do remember seeing a study several years ago that seemed to indicate that folks who had severe daytime sleepies were much more likely to adapt quickly to CPAP than folks who had far fewer problems with daytime sleepies as a symptom of untreated OSA. And that study said that the diagnostic AHI seemed have far less correlation with a quick adaption to CPAP than the severity of the daytime symptoms.

[robysue]

The severity of the apnea (in terms of the AHI) is not always reflected in the severity of the symptoms.

My diagnostic AHI was around 23, but I never had the daytime sleepies issues so many people have. My husband's diagnostic AHI was around 10, and he was falling asleep during the daytime and evening with alarming frequency. Neither of us had any issues with O2 desats noted on the diagnostic sleep studies.

Near as we can tell, my body had developed ways to cope with the nightly interruptions from the OSA and let me function during the daytime and my husband's body hadn't.

Finally for what it's worth, I do remember seeing a study several years ago that seemed to indicate that folks who had severe daytime sleepies were much more likely to adapt quickly to CPAP than folks who had far fewer problems with daytime sleepies as a symptom of untreated OSA. And that study said that the diagnostic AHI seemed have far less correlation with a quick adaption to CPAP than the severity of the daytime symptoms.

=========

or other things that apnea may have been at work
apnea is not the only cause of being tired and sleepy

Tiredness and sleepiness are the same thing.

In Hubby's case, it was the apnea that caused his daytime sleepies. And he was sleepy much more than being exhausted or tired. As soon as he started CPAP, he woke up during the daytime. When Hubby has excess tiredness issues, it's related to arthritis and old injuries from a very severe car crash in 1995, and no amount of CPAP will fix those things.

In my case, I was NOT sleepy during the daytime before I was diagnosed. Nor was I excessively tired before I was diagnosed, although in retrospect I was more tired then than I typically am now, but much of that daytime tiredness was due to chronic pain issues. One type of my chronic pain mysteriously disappeared about 6 months after starting CPAP, and that I think it may indeed have been apnea related. But eliminating most of my chronic pain issues has required working hard on getting my migraine, tension and TME headaches under control---none are related to my apnea, and all three of these got worse during my first year of PAPing.

[zoocrewphoto]

Well, the final report is in the hands of the doctors but not my hands - I have to go get a copy.

They did tell me I just have mild OSA - if that's true, why do I feel so lousy? I'm a stomach sleeper so they probably never got a back reading - could that be even worse?

Does mild OSA really need CPAP?

Thanks,

The mild, moderate, and severe categories are based on ahi (events per hour). They don't take itno consideration how long the events are, which could be causing your oxygen saturation to go way down. Also, some people have built up a coping mechanism of sleeping lightly so that they do not have a lot of events. Or their events are shorter than 10 seconds and don't count, even if they are disturbed by them. This can cause a mild diagnosis even when the person is sleeping like crap.

Mild is considered 5-15 events per hour. Even at 5 per hour, do you want to be disturbed 5 times an hour while you sleep? Most people feel better once they are below 2 per hour. And that's assuming you don't have longer events in clusters.

Also, as we age, we tend to get worse over time. When I was tested 5 years ago, I had 79+ events per hour. I didn't start that way. As a kid, I did not have sleep apnea. I doubt I went from 0 to 79 overnight. Due to my split night study and my lack of deep sleep or REM during that study, I was probably over 100 per hour. And I suspect I am worse now, 5 years later. Maybe not by much, and I'm already pretty severe. But it does get worse as you age. Ignoring it now will only allow damage to happen until you get treated later.

[TooNew]

I have the full report now.

Don't really have OSA - 1 mixed episode and 3 hypopneas.

However, in 6 hours 172 arousals and 22 wakenings. No REM while supine (RDI 31 per hour), PLMS 20 per hour, PVCs, tachycardias, and arrhythmias. SpO2 to 85% and longest hypopeic episode 29.5 seconds.

This all looks very strange to me and not clear cut - anyone have any info to explain it and what it means?

I expected a simple OSA issue - not sure if this type of report is common or not...

[Pugsy]

Sounds a lot like UARS Upper Airway Resistance Syndrome...google it and read up on it. While not really all that new, what is new is that the medical community are just now starting to pay closer attention to it. Treatment is still the same..cpap...not surgery for sure unless your lower mandible looks like Carol Burnett used to look before her jaw surgery and even then I don't know if it would help all that much.

Your oxygen level does concern me though. Below 88% for very long (and not being able to blame it on OSA or fix it with cpap will earn you full time added O2 to your life. I don't remember all the exact particulars. You need to look and see how long you spent at 85%...was it a brief thing or was it several minutes.

The arousals (whatever they are from) mess with your sleep architecture and the end result is you don't get the needed progression of the sleep stages and the right amount of % in each stage for the restorative powers of sleep to work their magic.

The PLMS of 20....could be a factor. Did they make a distinction in your report as to whether the arousals were related to PLMS (or PLMD by some people)...leg movement for the lay men.

The PVCs, tachycardia and arrhythmia...all heart related and you should get the heart checked out for sure...no matter what you do about the sleep disturbances. Separate issue...needs to be checked out.

There several kinds of arousals or reasons for the arousals.
Some could be related to the leg moving issue.
Some could be related to a reduction in air flow but not enough to earn a typical OA or hyponea flag.
Some could be normal sleep cycle arousal...like it's normal to have an arousal or awakening after REM .
Some could be what we call "spontaneous" and we don't know why they happened.

You may or may not remember arousals...a lot depends on how awake you become and if you quickly go back to sleep you won't likely remember it but the damage done to the sleep architecture has still occurred.

There's a lot more to "sleep disordered breathing" than just OSA.

Your back issues are also likely a factor. When we hurt we just seem to wake up more or have more arousals. I have issues with my back so I know how much it impacts sleep quality.

If your doctor thinks there is a chance of UARS being a factor he might offer cpap trial because it can help. It's harder to evaluate because the machines don't report the very things that are a factor in UARS except maybe FLs and/or RERA (Respiratory Event related Arousals) and even then we don't know just how accurate the RERA flagging is....and not all machines do the RERA flagging. Respironics does...ResMed does it on some models but not others...and again since the machine can't really tell if you are asleep or not it's really hard to know for sure.

What is odd is that they set you up for a titration sleep study with the AHI being so low and actually not diagnostic without even really talking to you about all this. Maybe they want to see what the heart stuff does with cpap...it wouldn't be impossible for those issues to be related to the arousals I suppose.

You are going to have some tough choices and it doesn't sound like a nice clear cut black and white OSA diagnosis to offer a clearer choice.
Especially now that we seemed to have you convinced that using cpap isn't the end of the world.

[TooNew]

Sounds a lot like UARS Upper Airway Resistance Syndrome...google it and read up on it. While not really all that new, what is new is that the medical community are just now starting to pay closer attention to it. Treatment is still the same..cpap...not surgery for sure unless your lower mandible looks like Carol Burnett used to look before her jaw surgery and even then I don't know if it would help all that much.

Looks like only UPPP has a chance to work

There several kinds of arousals or reasons for the arousals.
Some could be related to the leg moving issue.
Some could be related to a reduction in air flow but not enough to earn a typical OA or hyponea flag.
Some could be normal sleep cycle arousal...like it's normal to have an arousal or awakening after REM .
Some could be what we call "spontaneous" and we don't know why they happened.

You may or may not remember arousals...a lot depends on how awake you become and if you quickly go back to sleep you won't likely remember it but the damage done to the sleep architecture has still occurred.

I don't remember even the 22 wakenings - only 2 of them.

The arousals come from all sources apparently.

Your back issues are also likely a factor. When we hurt we just seem to wake up more or have more arousals. I have issues with my back so I know how much it impacts sleep quality.

I take Ibuprofen and flexeril which gives me 7-8 hours (normally) without back pain.

You are going to have some tough choices and it doesn't sound like a nice clear cut black and white OSA diagnosis to offer a clearer choice.
Especially now that we seemed to have you convinced that using cpap isn't the end of the world.

I think the world is going to end tomorrow night or early Saturday

[Pugsy]

No way in hell would I ever do the UPPP for UARS.

[robysue]

I have the full report now.

Don't really have OSA - 1 mixed episode and 3 hypopneas.

However, in 6 hours 172 arousals and 22 wakenings. No REM while supine (RDI 31 per hour), PLMS 20 per hour, PVCs, tachycardias, and arrhythmias. SpO2 to 85% and longest hypopeic episode 29.5 seconds.

That RDI = 31 is based on something. And that combined with the O2 drops to 85% and some events lasting as long as 29.5 is most likely why they set up the titration study.

You need to read the report a bit more carefully: Exactly what kind of events went into calculating the RDI? Because there's no way 4 events during the study equals an RDI of 31 events per hour. So some other kind of respiratory event WAS being scored and that other kind of respiratory event is interrupting your sleep every 2 minutes on average in order to have an RDI = 31.

Here's what you need to look for:

1) Were RERAs scored? If so, how many of them?

2) What definition of hypopnea was used to score the study?

3) Any chance the study distinguished between two types of hypopneas? If so, what are they and were there a whole lot of one that was counted towards the RDI not not the AHI?

There are two commonly accepted definitions of hypopnea, one an older one that is used by Medicare and one a newer one based on the idea that respiratory related arousals can be just as damaging as O2 desats.

• The older, "Recommended" Medicare-approved definition of hypopnea is: A 30% or more reduction in airflow that lasts at least 10 seconds and has a corresponding drop in SaO2 of at least 4%.
• The newer, "Alternative" definition of hypopnea is: A 50% or more reduction in airflow that lasts for at least 10 seconds AND one or both of the following: A drop in SaO2 of at least 3% OR an EEG arousal.

Some sleep labs will distinguish between "hypopneas with arousal" and "hypopneas with desaturation" and only include the "hypopneas with desaturation" in the AHI, but include both kinds in the RDI. RERAs are never counted in the AHI, but are always counted in the RDI.

Given the heart stuff (PVCs, tachycardias, and arrhythmias), it is important to consult with a cardiologist in my opinion. But it is also worth asking the sleep doc as well as a cardiologist if some of those events are in reaction to whatever it is that is making up the vast majority of your RDI events.

Finally, like Pugsy, I'd never have a UPPP for UARS. I'd try CPAP first.

[TooNew]

Here's what you need to look for:

1) Were RERAs scored? If so, how many of them?

68 total

2) What definition of hypopnea was used to score the study?

Average length was 22 seconds, longest was the 29.5. No other info on them though. Probably wasn't an issue with an AHI of only .6.

Finally, like Pugsy, I'd never have a UPPP for UARS. I'd try CPAP first.

Considering it has a pretty poor success rate and is supposed to be very painful, I must concur.

[Okie bipap]

Speaking from experience, UPPP surgery is very painful. I had the surgery about 20 years ago in an attempt to avoid using a cpap machine. I was never retested after the surgery, and just assumed it was successful since I no longer snored. The machines in use then were much larger and noisier than today's machines. There was a very limited choice of masks available. If they had today's choice of machines and masks available 20 years ago, I probably would not have the surgery.