New UARS patient? Standard Sleep Study NORMAL.

[tmr]

I read that there is two different protocols for scoring hypopnea that labs use. First one do require O2 desaturation to happen with the hypopnea , otherwise they wont score it. With the other one they will score hypopnea even without desaturation. So, she could have higher hypopnea index without it being shown in the report.

[Sludge]

How would a concussion, contusion, subdural hematoma, pain, and a skull fracture answer these valid questions ?

That's the point--

There are no valid questions.

[Sludge]

I read that there is two different protocols for scoring hypopnea that labs use. First one do require O2 desaturation to happen with the hypopnea , otherwise they wont score it. With the other one they will score hypopnea even without desaturation. So, she could have higher hypopnea index without it being shown in the report.

The "other" protocol requires arousals. And since there weren't any (see your previous question and subsequent response), that scenario cannot occur.

Those non-qualifying hypopneas would have been scored as RERAs and appeared in the RDI.

[Physician]

So her study was abnormal solely because of CO2 ?

[jnk]

Let's start from scratch on the old question-answering thingy, shall we?

. . . felt tired for six months despite eight hours of rarely interrupted sleep. . . .

That implies sleep troubles or overall health troubles, but could be stress, lifestyle, or other. It's good to check the breathing, but some people feel better on PAP even when testing (as in, the kind that insurance will accept) claims normal breathing all night.

. . . They would like her to try a CPAP machine at home for a few weeks . . .

In the context of insurance, that ain't a test. But in the context of helping patients, that is the ultimate test, if the pressure and manner of usage are optimized during those few weeks. And you say she feels better. So there ya go. She needs PAP. Now prove it to insurance using their arbitrary standards.

. . . Has anyone heard of this flow limitation problem existing while the usual sleep study is normal? . . .

Yes, we talk about it on here all the time. It's a basic recurring theme that seems to play in the background of most every thread longer than two or three pages. It may be the most common discussion of all, depending on how one scores each thread. The answer, I believe, is this: Tests are for one night and cannot actually rule out that an individual patient might benefit from the more-stable airway that results from proper use of PAP.

Please never, ever forget that names of conditions and diagnostic criteria are based on averages across populations and tell us (you) nothing about what an individual patient does or does not need. That is Doctoring 101, in my opinion. So don't let the insurance definitions distract you from that. You treat patients, not averages across populations. Dr. K. understands that, and he runs with it. Runs amok, in the opinion of some. Runs a darn-helpful clinic, in the opinion of others.

The Sludge Hammer is not FDA approved, by the way, to the best of my knowledge.

Just sayin'.

[Physician]

Isn't CO2 elevation and clinical improvement sufficient to warrant her insurance honoring a CPAP prescription from a Sleep Medicine physician ?

[jnk]

Isn't CO2 elevation and clinical improvement sufficient to warrant her insurance honoring a CPAP prescription from a Sleep Medicine physician ?

As a treatment for . . . ?

Hypoventilation? COPD? Overlap Syndrome? Scoliosis? Opioids? Neuromuscular issues? What?

Improving sleep by stabilizing the airway is one thing. Using PAP to hide a symptom, or a possibly important diagnostic finding, is another. And I assume that is what Sludge is hinting at for exploration, above.

Sounds out of the realm of simple CPAP for simple OSA and more a matter of NIV. So I think I'm sufficiently confused to conclude (finally) that this conversation must be way over my head.

My parting recommendation is, send her to Sludge. I mean, once he puts down that hammer.

[palerider]

My parting recommendation is, send her to Sludge. I mean, once he puts down that hammer.

I thought the hammer was self therapy for physician... *scratching head*

[jnk]

My parting recommendation is, send her to Sludge. I mean, once he puts down that hammer.

I thought the hammer was self therapy for physician... *scratching head*

With hammer therapy, I find that after the first blow, I drop the hammer, and then I wake up later all confused and in pain. But hey, just me.

My head only gets scratched, though, if I accidentally use the claw end of the hammer.

[palerider]

My parting recommendation is, send her to Sludge. I mean, once he puts down that hammer.

I thought the hammer was self therapy for physician... *scratching head*

With hammer therapy, I find that after the first blow, I drop the hammer, and then I wake up later all confused and in pain. But hey, just me.

well, sludge never said it would be effective therapy, or, at least not what effect he was looking for, though I have my suspicions.

[Sludge]

With hammer therapy, I find that after the first blow, I drop the hammer, and then I wake up later all confused and in pain. But hey, just me.

Right.

However, if one is already dazed and confused, the aforementioned BPH Therapy will properly realign the Thought Process (not dissimilar to the Science (HAHAHAHA) of Chiropracty).

In reverse order, the following are all of the OP's posts in this thread:

Isn't CO2 elevation and clinical improvement sufficient to warrant her insurance honoring a CPAP prescription from a Sleep Medicine physician ?

So her study was abnormal solely because of CO2 ?

She was NORMAL on her first study was ago.
This new study was NOT normal.

How would a concussion, contusion, subdural hematoma, pain, and a skull fracture answer these valid questions ?

Oooops. AHI = 3.0, RDI = 3.0
So would one treat her with CPAP ? If so, why ?

No arousals, but the study was abnormal.

0 (response to spontaneous arousals)

Her first sleep study weeks ago was completely normal.
Her AHI was 3.5, RDI = 3.0, TcC02 went to 65 tors most of the study. Lowest 02 saturation was 91. Sleep Efficiency 79%.
I''ve seen the summary and interpretation, but let's see what any of you think.

Agree. Leak is high, but she does not think it's leaking from anywhere expect the exhaust holes.
What data from an S8 are you seeking, other than what is listed above ? It has no card, so cannot use RM or SH software. Don't have the data cable.

During the past week, here are her average values. Your thoughts (other than leak seems too high) ?
Leak 0.5 L/sec.
AHI 8.5
AI 3.2
HI 5.8
Pressure 12

She has used CPAP every night, for whatever the reason, she feels the best she has in a year. Awesome. Yes, to get a CPAP machine and supplies, the DMEP requires a prescription, progress notes, and an abnormal PSG.

Yikes (response to slightly elevated leak). Will look again in two days.

Liters per second ? The LCD screen reads in L/min., right ?

Follow up of her values.
She has been using nasal pillows, but last night she used a Mirage FX nasal mask. Her values changed last night in that her HI, AI, and AHI dropped from the prior three nights. Why ?

--------- p -- p----- p -----mask

HI 6.7 - 9.6 - 10.3 -3.4
AI 5.4 - 4.5 - 4.1 - 2.9
AHI 12.1- 14.1- 14.4 - 6.3
LEAK 0.3 - 0.5 - 0.4 - 0.5
PRESSURE 10.6 - 11.0 - 10.0 - 0.8

After three days of CPAP following a normal sleep study she is about 80% better. More energy, concentration, better concentration, no napping, and far less yawning. Just plain awesome.

Why is an esophageal transducer required for the diagnosis of UARS ?

She will get the repeat and appropriate studies within two weeks. In the meantime she is feeling better on CPAP.

Last night's values:
HI 9.6
AI 4.5
AHI 14.1
Leak 0.5
Pressure 11
She'll get a chin strap today

Thank you. How does one explain her AHI = 0 (unofficially) during her sleep study?

Her values during her first use night. She elected to attach the humidifier and use nasal pillows.
Used 7.33 hours
HI 6.7
AI 5.4
AHI 12.1
Leak 0.3 L/S
Pressure 10.6

Another question: If an esophageal probe is required for this diagnosis, then why didn't her sleep study and all sleep studies include this probe? It's highly unlikely that insurance will allow a repeat sleep study just to look for this condition.

She had a formal in-patient 10 hour study with EEG, EKG, facial electrodes, chest and abdomen sensors, leg and calf sensors, nasal probe, but nothing esophageal.

WIKI: http://en.wikipedia.org/wiki/Upper_airw ... e_syndrome

Okay, Julie. Done.
How is flow limitation:
a) not diagnosed by a standard sleep study ?
b) diagnosed by the addition of swallowing a probe ?

A very slender 41 year old Chinese female who has felt tired for six months despite eight hours of rarely interrupted sleep. Often yawns repeatedly and requires a two or more hours daily nap. Physical exam (by her Internist) and lab work was normal. She had a complete overnight PSG (Sleep Study) which was normal, but no probe was put down her esophagus. Oxygen saturation was excellent at 99 all night.
She got a second opinion from a sleep specialist pointed out facial and throat features consistent with something which sounds like "Flow Limitation Disorder" or "Upper Airway Resistance Syndrome". She has a narrow high palate and small jaw. This sleep doc wanted to repeat the sleep study, but with "PES followed by MSLT" and this apparently includes swallowing a probe. See here: http://books.google.com/books?id=1C8G62 ... LT&f=false
They would like her to try a CPAP machine at home for a few weeks even though the sleep study was normal.
Has anyone heard of this flow limitation problem existing while the usual sleep study is normal ? Can one have flow limitation and a normal sleep study ?
She does NOT snore and her AHI is normal. I've observed and heard her sleep. She does not "struggle" to breath.

With the leak rate a little elevated, everyone dutifully replied "the leak is elevated" (and since that is an average, it could easily have meant a couple of acute displacements that skewed the data, and not requiring trying 70 different masks), and since the patient "felt better", that was the "acid test", so why bother with any objective, scientific data.

So after nearly a month, there comes the TcpCO2 of 65 mmHg (which, given the scenario of a slender 41 year old female, is the equivalent of "Oh BTW, her heart stopped. Was that important to know?"). However, given the OP's frequent ramblings, mistakes, typos, etc., who even knows if that is accurate (I mean, why do a TcpCO2 in the first place? That is critical information).

Anyway, if the OP wants to scan in primary data, a thought or two will be shared.

Otherwise, it's back to floundering (the fish, not the situation)(although I suppose one could flounder while floundering, but that would be a fluke).

[Guest]

So is that what happens when you play Physician on the internet?

[ChicagoGranny]

So is that what happens when you play Physician on the internet?

ROFLEW!



ChicagoGramps