Help Reading Sleep Study?

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Hopefullady
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Help Reading Sleep Study?

Post by Hopefullady » Wed Apr 22, 2015 7:19 am

Hi All. Can anyone help me decipher this or tell me if this study should be a cause to prescribe CPAP? I'm 49 years old. My weight has gone from 125-145 in two years due to exhaustion-related lack of "participating in life". Doc's recommendation was to have me sleep on stomach and/or side but I've been trying that for 15 years and have pain in arms and legs when on side, and pain in neck and lower back when on stomach. If I could sleep on my back it would be ideal but I choke every time I try. I also find it difficult to lose weight since I am so exhausted and I'm worried about having had heart palps for 2 or 3 years now. A recent Holter monitor showed I'm starting to have some real heart issues. I have another study scheduled (for additional "proof" for doc).
Thank you.

----------------------------------------------

Polysomnogram Interpretation Report

Epworth Score: 2/24

BMI: 25

MEDICAL HISTORY: Asthma, High blood pressure, Heart
palpitations

TECHNOLOGIST'S BEHAVIOR OBSERVATIONS: The patient arrived early
for her appointment. She was set up and habituated with a f&p
simplus full face mask. She fell asleep really quickly. She
maintained a snore through out the night. She had minor PLM's.
ECG was NSR throughout the night.


TESTING PARAMETERS:
The patient underwent a 19 channel attended overnight
polysomnography during which the following were recorded
continuously and simultaneously: frontal, central, and occipital
EEG (F3-M2, F4-M1, C3-M2, C4-M1, O1-M2, O2-M1), EOG, submental
and anterior tibialis EMG, ECG, oxyhemoglobin saturation by pulse
oximetry, thoracic and abdominal respiratory effort by inductive
plethysmography, Nasal/Oral airflow with a thermistor, nasal
pressure transducer, EtCO2 as indicated, snoring, body position,
and audio and video recording.

Sleep Scoring Data


Lights were turned off at 11:49 PM and lights were turned on at
4:24 AM. Treatment total recording time was 274.5 minutes and
total sleep time was 220.0 minutes. Sleep onset latency was 8.5
minutes and REM latency was 83.0 minutes. Sleep efficiency was
80.1%.

The patient spent 18.0 (7.6%) minutes in wake, 29.5 (13.4%)
minutes in stage N1, 112.5 (51.1%) minutes in stage N2, 54.5
(24.8%) minutes in stage N3, and 23.5 (10.7%) minutes in stage
REM. A total of 42 spontaneous arousals were noted with an index
of 11.45 per hour.

Respiratory Events

The apnea hypopnea index (AHI) is defined as the number of
hypopneas plus the number of apneas per hour of sleep. The apnea
hypopnea 4% index (AHI4%) is defined as the number of hypopneas
associated with greater than or equal to 4% SpO2 desaturations
plus the number of apneas per hour of sleep. The respiratory
disturbance index (RDI) is defined as the number of all
respiratory disturbances, including respiratory effort related
arousals (RERAs), per hour of sleep.

This study documented 0 obstructive apneas, 3 central apneas, 1
mixed apneas, 68 obstructive hypopneas, and 0 central hypopneas
over the 220.0 minutes of recorded sleep for a combined total of
72 apneas and hypopneas with an apnea hypopnea index (AHI) of
19.64 per hour. The supine AHI is 30.30, while the non-supine AHI
is 10.91. The total number of RERAs was 6 with a combined RDI of
21.27 per hour. The AHI4% is 2.18.

A total of 5 desaturations were noted with an oxygen desaturation
index (ODI) of 1.1. The patient's mean oxygen saturation was 95%.
The lowest recorded SpO2 saturation was 89%. The patient spent 0
minutes with an SpO2 at or below 88%, which was 0.0% of the total
sleep time.

Cardiac Events

The mean heart rate during sleep was 65 beats per minute. The
highest heart rate recorded during sleep was 76 beats per minute.
The highest heart rate recorded during sleep or wake was 88. The
lowest heart rate recorded during sleep was 60. The ECG showed
Normal Sinus Rhythm, PVC's.

Movement Events

A total number of 8 periodic limb movements were noted during
sleep, 5 associated with arousals, yielding a periodic limb
movement index of 2.18 per hour and a periodic limb movement
associated with arousal index of 1.36.

DIAGNOSTIC IMPRESSIONS:

Mild sleep disordered breathing with AHI 4% of 2.9. Using
alternative criteria, mild sleep disordered breathing with AHI 3%
was 19 events per hour. No hypoxemia. Poor sleep efficiency due
to difficulty with sleep lab environment.

INTERPRETATION:

No periodic breathing. Mild sleep disordered breathing worse in
supine position.

RECOMMENDATIONS:

Avoid supine sleep if possible. Avoid sedatives. Maintain nasal
patency. Repeat PSG if high suspicion for OSA persists.


780.54/diagnostic

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Pugsy
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Re: Help Reading Sleep Study?

Post by Pugsy » Wed Apr 22, 2015 8:02 am

Yes...the results earn you a CPAP RX.
Hopefullady wrote: combined total of
72 apneas and hypopneas with an apnea hypopnea index (AHI) of
19.64 per hour. The supine AHI is 30.30, while the non-supine AHI
is 10.91. The total number of RERAs was 6 with a combined RDI of
21.27 per hour.
It's worse on your back but even on your side it's almost 11 per hour and with high blood pressure involved you have co-morbid factors along with the general lack of energy stuff.
You are fortunate the the oxygen levels didn't drop dangerously low.

Also these are hourly averages...and most of the time these events aren't space evenly throughout the night...they usually come in clusters so you have some time with not much going on and sometimes with a whole lot of stuff going on. The bunching together of these events tends to disturb sleep more and the more our sleep is disturb the less restorative it can be.

I don't know if it is feasible for you to try to always sleep on your side...it's easier said than done.
So I don't know if you were able to sleep only on your side if you could get by without cpap...10 per hour with co morbid factors is still more than I would want to risk.

If you can't stay on your side 100% of the time...there is no question at all...get the cpap...and it's iffy to do without cpap if you can stay on your side all the time.

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Hopefullady
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Re: Help Reading Sleep Study?

Post by Hopefullady » Wed Apr 22, 2015 8:41 am

Thank you so much Pugsy. I honestly can't wait another month. I'm calling doc today to just ask for CPAP.

Another question I have is, is CPAP the usual recommended treatment? I am reading about something called BIPAP too I think. I've already looked into dental devices and other more "extreme" things and I'm not considering those. I simply don't want to be asking for the wrong thing. Sleep doc is away so I'll have to call PCP.

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Pugsy
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Re: Help Reading Sleep Study?

Post by Pugsy » Wed Apr 22, 2015 8:53 am

Yes...cpap is the usual treatment.
BiPap (bilevel) is just a different machine that offers more pressure options and may or may not be of benefit to you.
BiPap is actually Respironics marketing term for bilevel device. ResMed calls them VPAP or AirCurve depending on model line.

Bilevel devices themselves come in various models from the basic bilevel to the high end that treats centrals.

Bilevel devices can go to 25 cm pressure and offer a wide range between inhale and exhale that helps with breathing.
Cpap/apap devices are limited to 20 cm but to be honest if your pressure needs are in the teens on cpap...bilevel would likely be more comfortable.
Cpap/apap devices also have some form of exhale relief depending on which brand.

You may or may not benefit/need bilevel. It would depend on what your pressure needs are to keep the airway open and how well you deal with those pressure needs.
Bilevel is also useful when people experience a lot of aerophagia (belly pain, gas, bloating) even at lower pressures because it allows more reduction to help reduce the air getting into the belly.

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Julie
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Re: Help Reading Sleep Study?

Post by Julie » Wed Apr 22, 2015 9:10 am

Maybe you need to look at a better bed, like memory foam, etc. If you could stay off your back, you probably wouldn't need cpap at all.

Hopefullady
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Re: Help Reading Sleep Study?

Post by Hopefullady » Wed Apr 22, 2015 9:36 am

Thanks both.
My breathing problem is only when breathing out. And I don't have belly issues etc. I will discuss this with doc or Medicare-contracted company.

Julie, good point about the bed. I know my problem is multifactorial and sleep hygiene and eating well, low caffeine intake and all that stuff is also very important. Regarding just the bed alone, I have an issue that further complicates my ability to be comfortable in bed: an allergy to chemicals (MCS), which began in 2012 after a very traumatic event followed by an exposure to mold in a hideous apartment I moved into. I got very sick and my brain is overloaded with toxins (emotional & chemical) so when I sleep in memory foam I get angiodema (lips swell up). It's very scary so I have to have an "organic" bed (hard materials like cotton and wool!) I use a natural latex topper but latex doesn't perform quite like the memory foam I used to love.

Combination stomach and side sleeping is what I prefer but it's difficult to satisfy. One needs a firm, supportive bed for stomach - with as thin as possible a comfort layer for pressure relief while on side, but not too thick or hips "sink" while on stomach, causing lower back "sway" and pain. Stomach/side sleepers usually don't ever find a perfect bed - but yes, a thinner memory foam topper is what I've found to be best! Unfortunately I can't use it.

I can't tell you how many beds I've been through these last few years...I've tried every type & thickness of latex with all different beds and if I could just sleep on my back I might not keep waking up with arm, leg or back pain.

I'm trying to fix the physical first (get some rest), so I have a shot at addressing everything else.

I know we all have our stories
Last edited by Hopefullady on Wed Apr 22, 2015 9:40 am, edited 2 times in total.

Sleeprider
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Re: Help Reading Sleep Study?

Post by Sleeprider » Wed Apr 22, 2015 9:36 am

Hopefullady wrote:Thank you so much Pugsy. I honestly can't wait another month. I'm calling doc today to just ask for CPAP.

Another question I have is, is CPAP the usual recommended treatment? I am reading about something called BIPAP too I think. I've already looked into dental devices and other more "extreme" things and I'm not considering those. I simply don't want to be asking for the wrong thing. Sleep doc is away so I'll have to call PCP.
Since your diagnostic study did not evaluate positive air pressure effect on your apnea and hypopnea, you have not been titrated for CPAP. You will require either an Auto CPAP or further evaluation to prescribe a treatment pressure. Clearly, there is a significant cost advantage to getting an Auto CPAP and self-titrating. The only downside to that approach is if you are one of the few people that actually develop complex apnea when subjected to CPAP pressure. The presence of a few centrals may make your doctor reluctant to prescribe APAP, however because the machines produce data, you would be aware of any central apneas that result from CPAP therapy.

You indicate you want to call the doctor about obtaining a CPAP machine. You actually want is an auto-titrating CPAP (APAP). Without a diagnostic study and other qualifiers you would not currently qualify for insurance reimbursement for bilevel devices at this point. A bilevel device would make exhalation easier, and if this is a comfort issue, or improves treatment efficacy your only option would be to obtain a titration study that evaluates both CPAP and Bilevel pressure. Most insurance however will require you to fail CPAP before they will pay for the more expensive bilevel machine. The study could also reveal complex apnea induced by CPAP, which would require a third type of machine, bilevel adaptive servo ventilation (ASV).

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Hopefullady
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Re: Help Reading Sleep Study?

Post by Hopefullady » Wed Apr 22, 2015 10:02 am

[quote="Sleeprider"
Since your diagnostic study did not evaluate positive air pressure effect on your apnea and hypopnea, you have not been titrated for CPAP.
Thank you, Sleeprider. I'm doing my best to "quote" and respond on my IPhone...regarding the above, do you mean I wasn't tested for something specific?
You will require either an Auto CPAP or further evaluation to prescribe a treatment pressure. Clearly, there is a significant cost advantage to getting an Auto CPAP and self-titrating.
Is an "auto-CPAP" a regular CPAP machine or something else? I'm having trouble following what the above means. Any clarification or putting it in simpler terms for me would be appreciated.
The only downside to that approach is if you are one of the few people that actually develop complex apnea when subjected to CPAP pressure. The presence of a few centrals may make your doctor reluctant to prescribe APAP, however because the machines produce data, you would be aware of any central apneas that result from CPAP therapy.
I'm confused...I can develop worse apnea by using certain machines, but this potential can be monitored?
You indicate you want to call the doctor about obtaining a CPAP machine. You actually want is an auto-titrating CPAP (APAP).
Without a diagnostic study and other qualifiers you would not currently qualify for insurance reimbursement for bilevel devices at this point. A bilevel device would make exhalation easier, and if this is a comfort issue, or improves treatment efficacy your only option would be to obtain a titration study that evaluates both CPAP and Bilevel pressure. Most insurance however will require you to fail CPAP before they will pay for the more expensive bilevel machine. The study could also reveal complex apnea induced by CPAP, which would require a third type of machine, bilevel adaptive servo ventilation (ASV).[/quote]
Your full response seems important. Can you clarify it for me?
Many thanks!

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Pugsy
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Re: Help Reading Sleep Study?

Post by Pugsy » Wed Apr 22, 2015 10:25 am

cpap/apap...2 modes of pressure delivery
cpap is a fixed single pressure delivery mode...you get a fixed pressure all night and it doesn't vary
apap is a single pressure delivery mode but it can auto adjust or fluctuate during the night per what the machine thinks needs to be done. So an apap is a cpap machine but simply has additional modes of operation available.

An APAP capable machine will have cpap mode available in addition to apap mode.
A machine that does only cpap mode won't have apap mode available...and while not every one needs or wants apap mode availability...it's nice to have just in case.

Bilevel...2 pressures are delivered instead of just 1. So a different pressure on inhale and exhale above and beyond any changes that cpap/apap machines might offer in the form of exhale relief.
At this point we have no idea if you even need what a bilevel offers and for sure based on only the diagnostic sleep study...wouldn't meet insurance requirements. Cross that bridge if and when you come to it.

Yes...sometimes cpap/apap pressure causes centrals in some people. I think 10 to 15% of the people. Not all that common but not all that rare either. Not to worry about that right now....the new machines that are full data machines will clearly let you know if you fall into this category and we get to have another discussion. Again, cross that bridge if and when you come to it. Everyone has a few centrals here and there and it doesn't mean anything alarming. Centrals are only a problem when present in large numbers, causing extensive sleep disruption or oxygen level drops.

Advising you to get an apap machine and bypassing the titration sleep study (where you sleep with the cpap machine in a sleep lab) would enable you to more easily figure out your optimal pressure settings...but it can be done with a cpap only machine.
Always try to get the most for your money though...apap capable machines are billed out under the same billing code as cpap mode only machines..so insurance pays the same for either...so get the machine that has more options if at all possible.
Even if buying out of pocket...I still suggest getting apap capable if at all possible. There are some situations where having auto adjusting capabilities are a distinct advantage.
The cost out of pocket between the cpap and apap models...not huge.

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Hopefullady
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Re: Help Reading Sleep Study?

Post by Hopefullady » Wed Apr 22, 2015 2:32 pm

Thanks for this clarification. Seems apap is much better. I also did notice before I went to sleep and they tested the CPAP on me, it was very uncomfortable breathing out. My problem with apnea is only while
breathing out (that I have noticed) so...

If anyone's still on this thread, I guess I'm just wondering if the testing they did was thorough - and I'm still confused about whether my study looks good or qualifies me for apap or CPAP (I think most of you said No?)
Thank you again.

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Pugsy
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Re: Help Reading Sleep Study?

Post by Pugsy » Wed Apr 22, 2015 3:19 pm

Yes, your study results qualify you for cpap/apap therapy under most insurance requirements.
Even for medicare and people with no other conditions (like your hypertension or heart issues) an AHI of 15 will meet the requirements and over 5 AHI if a person has other co morbid factors (like hypertension or heart issues or excessive daytime sleepiness).

Yours is mild when side sleeping and moderate overall and worse when sleeping on your back.
Hopefullady wrote:apnea hypopnea index (AHI) of
19.64 per hour.
http://en.wikipedia.org/wiki/Apnea%E2%8 ... pnea_index
Normal: 0-4
Mild Sleep Apnea: 5-14
Moderate Sleep Apnea: 15-29
Severe Sleep Apnea: 30 or more

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Hopefullady
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Re: Help Reading Sleep Study?

Post by Hopefullady » Wed Apr 22, 2015 3:56 pm

You folks here are amazing. I cannot thank you enough for taking the time to look at my situation so closely. It's a tremendous help.

Hopefullady
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Re: Help Reading Sleep Study?

Post by Hopefullady » Mon Apr 27, 2015 12:00 pm

Just spoke with doc. He says Medicare will not pay for me to have a device because this wasn't high enough, even with comorbidity factors (heart problems).

Mild sleep disordered breathing with AHI 4% of 2.9. Using
alternative criteria, mild sleep disordered breathing with AHI 3%
was 19 events per hour. No hypoxemia.


What say you?

One other factor: sleep lab was horrible. Techs were talking down to me all night so I left angry. They "played victim" to protect themselves and the incident is now on my medical record dishonestly, making me look bad. I wonder if doc is tainted by reading that. This could be paranoia on my part, but people are people and can't always help developing a bias. (I will have to deal with that report when this is done.)

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Pugsy
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Re: Help Reading Sleep Study?

Post by Pugsy » Mon Apr 27, 2015 12:25 pm

Where are they getting the AHI % thing?
That's not common at all.
AHI is usually just a number and I have never seen a report state AHI ?% then a number like 19 after it.
Unless the 19 isn't AHI but instead is the total number of events over the sleep session.

Example: 3 hours of sleep...so 180 minutes and 30 events over the 3 hours and the AHI would be 10...so an average of 10 per hour.

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Hopefullady
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Re: Help Reading Sleep Study?

Post by Hopefullady » Mon Apr 27, 2015 12:41 pm

Doc said my AHI was only 2.9 and needed to be 5.
Sorry I wasn't more specific.