New UARS patient? Standard Sleep Study NORMAL.

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
Physician
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New UARS patient? Standard Sleep Study NORMAL.

Post by Physician » Wed Jul 16, 2014 6:55 pm

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.
Last edited by Physician on Wed Jul 16, 2014 7:23 pm, edited 4 times in total.

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Julie
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Re: Ever heard of a normal sleep study but "flow limitation" ?

Post by Julie » Wed Jul 16, 2014 7:06 pm

UARS (upper airway resistance syndrome) is a known, if not always recognized, condition that some forum members have and if you change the title of your thread to New UARS patient? or something like that, rather than focusing on the flow limitation which is also present in apnea, you should get many replies and lots of information.

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Re: Ever heard of a normal sleep study but "flow limitation" ?

Post by Physician » Wed Jul 16, 2014 7:09 pm

Julie wrote:UARS (upper airway resistance syndrome) is a known, if not always recognized, condition that some forum members have and if you change the title of your thread to New UARS patient? or something like that, rather than focusing on the flow limitation which is also present in apnea, you should get many replies and lots of information.

Okay, Julie. Done.

How is flow limitation:

a) not diagnosed by a standard sleep study ?

b) diagnosed by the addition of swallowing a probe ?

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Julie
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Julie » Wed Jul 16, 2014 8:00 pm

I'm not aware that FL is either dx'd or not dx'd by a standard study - I only know what it means on my results in the mornings if it's noted... and I don't claim to know any more, which is why I said more info would be forthcoming by others who do know more about UARS, which I read as the primary problem, so pointed it out.
Last edited by Julie on Wed Jul 16, 2014 8:37 pm, edited 1 time in total.


Soundsleepservices
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Soundsleepservices » Wed Jul 16, 2014 9:07 pm

The problem here is a slight closure in the airway often causes microarousals. This would be the issue to look at with this woman. UAR has been around for quite some time but insurance often doesn't like to pay for their therapy. The sleep study, if it was a home sleep study, won't have the brain waves. An in lab sleep study however is indicated for her and recommended by sleep physicians and the sleep industry as a whole. It would include leads attached to her head to measure the brain waves, detecting changes in sleep staging from one stage to another, lack of REM sleep, lack of deep sleep (stage three or delta waves) and - arousals.

If no problems are detected, perhaps it's a neurochemical problem which naturopaths frequently can easily test for through the patient's spit, an affordable, accurate and painless process.

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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Physician » Wed Jul 16, 2014 9:53 pm

Soundsleepservices wrote:The problem here is a slight closure in the airway often causes microarousals. This would be the issue to look at with this woman. UAR has been around for quite some time but insurance often doesn't like to pay for their therapy. The sleep study, if it was a home sleep study, won't have the brain waves. An in lab sleep study however is indicated for her and recommended by sleep physicians and the sleep industry as a whole. It would include leads attached to her head to measure the brain waves, detecting changes in sleep staging from one stage to another, lack of REM sleep, lack of deep sleep (stage three or delta waves) and - arousals.

If no problems are detected, perhaps it's a neurochemical problem which naturopaths frequently can easily test for through the patient's spit, an affordable, accurate and painless process.

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.

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Here's another question.

Post by Physician » Wed Jul 16, 2014 10:20 pm

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.

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Any thoughts on these values from the CPAP ?

Post by Physician » Thu Jul 17, 2014 9:47 am

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

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Julie
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Julie » Thu Jul 17, 2014 9:55 am

Looks to me like she does have (if mild) apnea, unless it's completely positional... AHI being 12.

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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Physician » Thu Jul 17, 2014 10:08 am

Julie wrote:Looks to me like she does have (if mild) apnea, unless it's completely positional... AHI being 12.

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

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Julie
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Julie » Thu Jul 17, 2014 10:34 am

I guess it would depend on the place, the expertise (& education) of the people involved, it wouldn't be the first time an initial study was proven to be wrong, for whatever reason it happened... then again, without being hands on re the stats you showed, who knows what's correct? From your description of her, she sounds like an OSA candidate for anatomical reasons, but one needs to get some kind of consensus about things after all... and we can only speculate.

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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by jnk » Thu Jul 17, 2014 4:21 pm

Sleep studies study ONE night. But we sleep EVERY night. UARS can be a sneaky elusive devil that hides some nights.

Have her have a PSG (or HST) flat on her back (if she can make herself sleep that way) after an exhausting day and a big meal with a few glasses of wine or some allergy meds just before the study to rig the numbers for insurance so they will pay for a PAP trial for mild OSA.

That's a joke, but I'm only half kidding. Actually . . .

The data from the PAP trial or HST can be slyly integrated into the PSG data by a skilled doc in order to hide the true source of the data from the insurance police so that the PAP machine will get paid for.

The larger issue is that highly sensitive UARS patients and mild OSA patients (often a distinction without a difference, in practice, as far as treatment goes) don't always do well on PAP without a lot of skilled attention and patience.

Oh, and these days the equipment is sensitive enough to catch flow limitation without the patient swallowing anything. So the trick is to know what to look for and how to fudge the data when scoring the PSG. In other words, it might be easier to, ahem, rescore the original PSG than to put the patient through another one. If so, say so by phone and don't keep records of that conversation between you and the lab.Just ask them to look more closely at the data to make sure more of those events can't be scored as hypopneas.

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justinjustin
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by justinjustin » Thu Jul 17, 2014 5:10 pm

Physician wrote:
Julie wrote:Looks to me like she does have (if mild) apnea, unless it's completely positional... AHI being 12.

Thank you. How does one explain her AHI = 0 (unofficially) during her sleep study?
Do you have her RDI (Respirator Disturbance Index) as well? This can also be telling for UARS.

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Rustsmith
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Rustsmith » Thu Jul 17, 2014 6:01 pm

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.
Many sleep labs are not trained in the use of an the esophageal probe nor are they set up with the rest of the equipment to monitor the pressure. I had the esophageal probe test and it was rather uncomfortable, but not painful. I think that it played a larger role in my abnormally disturbed sleep that night than did the multitude of wires. It is therefore not something that a lab would want to do on patients who are more likely to have regular sleep apnea.

I also agree with justinjustin that the telling score for UARS during the sleep test would be the RDI rather than AHI. Since UARS tends to awaken the individual as the airway closes prior to actually getting to the point of an apnea or hypopnea, the RDI's inclusion of micro-awakenings from the EEG provides a better picture than the respiratory AHI value.

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