Sleep doc says the machine I wanted is ****, do you agree?

[StillAnotherGuest]

I'm still not "getting it" that turning off IFL1 would be tantamount to saying all of the flow limitations are unresponsive, so we're not going to look at any flow limitations.

No prob. To review:

I told him I was most interested in the Puritan Bennett GoodKnight 420E, and he (her MD) said it's ¢*** and doesn't react fast enough to events

With a response of 0.1 cm H2O to address flow limitations without concomitant hypopnea, I imagine that's what given him cause to label 420E a slug. And if you get that thing and turn the IFL1 off, it won't respond at all.

I had no apneas and IIRC my AHI was 1.7 if you only count hypopneas leading to desats, 4.6 including all hypopneas, and my RDI was 5.7. I know my AHI was just under 5 and my RDI was just under 6.

I know I had 26-27 hypopneas and I would have needed to have 28-29 for my insurance to cover treatment, and I also had about 8-10 RERAs, which the study defined as flow limitations of less than 30% that caused arousals.

IFL2 will therefore only address about 30 events. And since you're already starting on at least 5 cmH2O of CPAP, I'd be willing to bet that most, if not all, of those hypopneas will be gone. You'd think those RERAs with only a 30% reduction in amplitude wouldn't give a lot for IFL2 to grab onto even if they weren't already gone with the 5.

So now we're left with

constant flow limitations that caused neither arousals nor desats.

WIthout arousals, there won't be the "normal" resuscitive breaths that would then characterize the FL as having amplitude decrease, so IFL2 won't pick it up. Without those "normal" breaths, then "runs" might not be delineated either (THAT would be interesting to see doing that Window Snapshot thing).

So now the possibilities are:

(1) IFL1 is left on, works properly and the FLs will be identified and addressed. There is concern by the physician that the response might be too slow (yet you could also argue that even if it is, the lack of arousals suggests that there aren't any events per se, so any delay might be academic anyway).

(2) Runaways develop and you're forced to turn IFL1 off. Now for all intents, it won't respond to anything, because all's that's left is FLs.

That's why it's a good idea to drive before you buy.

Tillymarigolds, did you have an esophageal catheter in place during the study? You've got a really sparse number of events, but I suppose if you're using the 2005 Guilleminault criteria, those patients also had very low RDIs as well as AHIs, but they were using esophageal catheters to document the effect of the flow limitation.
SAG

[tillymarigold]

Tillymarigolds, did you have an esophageal catheter in place during the study? You've got a really sparse number of events, but I suppose if you're using the 2005 Guilleminault criteria, those patients also had very low RDIs as well as AHIs, but they were using esophageal catheters to document the effect of the flow limitation.

No, my sleep doc was convinced I had apnea after the first consult so no catheter. So when the results came back looking as they did, he said (and I quote), "Well, we could stick a catheter up your nose and down your throat and do another sleep study and get a definitive diagnosis of UARS, or we could give you a 30 day trial with an auto PAP machine and if that cures your symptoms, we'll say it's almost certain you do have UARS. The auto PAP is cheaper and less painful." Hence the auto PAP trial.

[rested gal]

he said (and I quote), "Well, we could stick a catheter up your nose and down your throat and do another sleep study and get a definitive diagnosis of UARS, or we could give you a 30 day trial with an auto PAP machine and if that cures your symptoms, we'll say it's almost certain you do have UARS. The auto PAP is cheaper and less painful." Hence the auto PAP trial.

"less painful" -- reminded me of something funny I read on a board many sleep techs frequent:

In a 2004 topic, one of the techs asked:
Several years ago it seemed like esophageal pressure monitoring (Pes) was becoming a standard in polysomnography. I haven't heard much about it lately. Are many centers/labs still using Pes or is this invasive procedure fading out?


Among the replies by other techs was this:
In the center I ran there was a physician who wanted to do this. He did not know, could not tell me, what the normal values would be so, he decided he would wear one and be monitored all night to establish a baseline. He showed the technologist how to place the catheter, on me. Then the technologist nervously placed it on him. He had it in for about 15 seconds, tossed his cookies then exclaimed he would never put a patient through that.

[sleepyred]

Welcome! I have UARS as well! I am using a REMstar Auto with C-Flex and am quite happy with it. I am working (with some wonderful help from Goofproof, Blarg, Wulfman, Rested Gal, Dreamstalker) to set my machine/pressure.

I'm staying on apap right now - 7-10 pressure. If I go to cpap, I will probably use 9.

Good luck! Cpap treatment for me has been wonderful!

Just curious - how did you end up with your diagnosis - ie - what were your symptoms? I was so fatigued and would walk up feeling like I was in a fire or that I could not swallow.

Sleepyred

[tillymarigold]

Just curious - how did you end up with your diagnosis - ie - what were your symptoms? I was so fatigued and would walk up feeling like I was in a fire or that I could not swallow.

The grounds for the study were excessive daytime sleepiness, serious brain fog, lack of concentration, morning headaches, a narrow airway (Mallampati Class 3), a family history of I-won't-get-a-sleep-test-but-I-have-all-the-symptoms (my mother has all the symptoms I do plus high blood pressure, heart palpitations, swollen ankles, frequent nighttime urination, and she snores like a buzz saw, which I don't), and having tried changes in diet, lifestyle (exercise), bed, and antidepressants.

The symptoms plus the PSG results of borderline AHI and RDI and the FLs led to the diagnosis which was confirmed by the APAP results.

[Guest]

In my experience, Respironics and ResMed make the more reliable machines. My experience is based on performing sleep studies for almost 20 years, DME feedback and patient feedback. We have four 20 year old Respironics BIPAP ST machines that still work! As far as the noise, I have had patients complain that the new machines are too quiet! One big advance seems to be CFLEX. In the lab we have seen positive results with CFLEX during the titration and most DME's report better compliance with patient's that use CFLEX. I know that ResMed and other manufactures have something similar but I don't have any personal knowledge of those or any direct feedback.

I have seen some examples of respiratory events in this thread but some of the examples are missing some important information. Displaying just airflow is not enough. For better accuracy, you also need abdominal and thoracic effort, oxygen saturation and arousal detection(EEG). The only difference between a hypopnea and a RERA is the hypopnea has the major desaturation. If just monitoring airflow, both events could look the same. Likewise without the other parameters, an obstructive apnea and a central apnea look the same also.

I am curious to find out if your insurance co. pays for your pressure therapy with your diagnosis of UARS. In my opinion, UARS and RERA should be also treated with pressure therapy since they are arousal disorders.

Good Luck...Joe

[Guest]

The only difference between a hypopnea and a RERA is the hypopnea has the major desaturation. If just monitoring airflow, both events could look the same. Likewise without the other parameters, an obstructive apnea and a central apnea look the same also.

Not according to the parameters of my sleep study, they're not. A "true hypopnea" was defined as a 30% reduction (or more) in airflow with desaturation (with or without arousal), a "partial hypopnea" was defined as a 30% reduction (or more) in airflow with arousal (with or without desaturation), and an RERA was defined as a less than 30% reduction in airflow that led to an arousal. A flow limitation being any reduction in airflow of any amount that led to neither arousal nor desaturation.

I am curious to find out if your insurance co. pays for your pressure therapy with your diagnosis of UARS. In my opinion, UARS and RERA should be also treated with pressure therapy since they are arousal disorders.

Well, in my opinion I agree with you, but as I've several times in this thread, my insurance is $*** and has already let me down in a variety of ways in the 6 months I've been with them, despite being the best available insurance in the state. I was lucky they paid for my auto PAP trial. Then again, they pay so little for CPAP machines and the authorized DME charges so much, that it was cheaper to buy it online than pay the copays anyway.

Health care out here in New Mexico sucks and insurance is worse. My sleep doc is great (though a bit bitchy when I don't bow to his wishes) and it was a very good call by my PCP, but other than that the medical care is horrid. Partly 'cause we're underserved (for most specialties, the entire state including the major cities is considered an under-served area that doctors get their loans paid off if they come work here).

[Snoredog]

Not according to the parameters of my sleep study, they're not. A "true hypopnea" was defined as a 30% reduction (or more) in airflow with desaturation (with or without arousal), a "partial hypopnea" was defined as a 30% reduction (or more) in airflow with arousal (with or without desaturation), and an RERA was defined as a less than 30% reduction in airflow that led to an arousal. A flow limitation being any reduction in airflow of any amount that led to neither arousal nor desaturation.

Sounds to me you need to find an acredited sleep lab, one that conforms to the quidelines established by AASM/ABSM, because what you quoted above is not according to those guidelines. The only thing missing from your posts so far is your sleep doctor has financial interest in the Sleep Center, then that would explain everything.

Why else would they want to lower the criteria for diagnosing a Hypopnea from 50% reduction lasting >10 seconds associated with at least a 3% drop on oxygen level.

It is NOT 45%, or 40% or 30% it is 50% reduction in airflow lasting longer than 10 seconds and associated with a 3% drop in oxygen level.

If it is only 30% reduction in flow or only lasts 9 seconds or has only a 2% drop in oxygen level it is classified as a Flow Limitation not Hypopnea.

Apnea is just that a complete cessation of airflow >10 seconds.

here are some other terms you might find:
DEFINITIONS:
APNEA = cessation of airflow for 10 seconds or greater.
HYPOPNEA =>50% decrease in airflow for 10 seconds or greater with a decrease in oxygen saturation of >3%.
APNEA/HYPOPNEA INDEX (AHI) = apnea plus (+) HYPOPNEA/hour of sleep.
RESPIRATORY AROUSAL INDEX (RAI) = AHI +snoring related EEG arousals/hour of sleep.
AHI/RAI** Scale =<5 events /hour = (none); 5-15 events/hour = (mild); 15-30 events/hour = (moderate); >30 events/hour = (severe).
Respiratory related sleep fragmentation: Sleep arousals due to respiratory events or snoring.
Desaturation = Drop in O2 oximetry distribution saturation by 3% below average saturation.
SaO2 scale: >89%=(none); 85-89%=(mild);80-84%=(moderate); <80% (severe).
EPWORTH SLEEPINESS SCALE =<10=(does not indicate EDS (Excessive Daytime Somnolence));10-15=(indicates daytime somnolence-not excessive);>16 (indicates EDS).
RESPIRATORY EFFORT RELATED AROUSALS (RERAs)=Sleep Arousals due to respiratory events characterized by pressure flow limitations in the airflow indicator channel without significant O2 desaturations.
StageIII and StageIV are combined and referred to as Deep Sleep.
Sleep Efficiency = Normal is >80%
As established by AASM/ABSM 1999.

Normal Sleep Architecture:
Stage1: 5%
Stage2: 50%
Stage3: 10%
Stage4: 10%
Stage REM: 25%

Stage3&4, REM decrease as we age.


Stuff seen on a PSG Report:

Arousal: An interruption of sleep lasting greater than 3 seconds.

BR Arousal index: The number of breathing related arousals(apnea, hypopnea, snoring & RERAs)multiplied by the # hours of sleep.

Bruxism: Grinding of the teeth.

Central apnea: A respiratory episode where there is no airflow and no effort to breathe lasting greater than 10 seconds.

EEG/EOG: Comments about sleep stages, brain waves (EEG), or eye movements (EOG)

EKG/ECG: Comments about heart rate, abnormal heart beats, etc.

EMG: Comments about leg movements and or teeth grinding (bruxism).

Hypopnea: A respiratory episode where there is partial obstruction of the airway lasting greater than 10 seconds. Also called partial apnea or hypo-apnea.

Non-supine: Sleeping in any position other than on the back.

NSR: Normal sinus rhythm.

NPSG: Nocturnal Polysomnogram, or sleep study.

(#)Number of Awakenings: The number of pages scored as wake after sleep onset.

Obstructive apnea: A respiratory episode where there is a complete cessation of airflow lasting greater than 10 seconds.
PLMs: Periodic limb movements.

PLM arousal index: The number of periodic limb movements that cause arousals multiplied by the number of hours of sleep.

PSGT: Polysomnographic technologist.

REM latency: Latency to REM(dreaming) from sleep onset.

RERAs: Respiratory effort related arousals. Episodes that are not apneas or hypopneas, often related to loud snoring, that generally do not cause a decrease in oxygen saturation.

Respiratory: Any specific comments about respiratory events.

RPSGT: Registered polysomnographic technologist.

Sleep efficiency: Total sleep time multiplied by time in bed.

Sleep latency: The first 30 seconds (one `epoch' of recording time) of sleep.

Sleep onset: The first 90 seconds (3 `epochs) of uninterrupted sleep.

Sleep stage shifts: The number of incidents of sleep stage changes.

Snoring intensity: Level of snoring loudness determined by the sleep technologist. Ranging in degrees from mild to very loud snoring.

Spontaneous arousal index: The number of spontaneous arousals (e.g. arousals not related to respiratory events, limb movements, snoring, etc) multiplied by the number of hours of sleep.

Stage 1: The lightest stage of sleep. Transitional stage from wake. top

Stage 1 shifts: The number of times the sleep stage changed to stage 1.

Stage 2: The first true stage of sleep.

Stages 3/4: The deepest, most restorative sleep.

Stage REM: The dreaming stage; Normally occurs every 60-90 minutes.

Supine: Sleeping on back.

Time in bed: The time in the study from `Lights Out' to `Lights On'.

Total arousal index: Total number of all arousals multiplied by the number of hours of sleep.

Total # of PLMs: The number of leg movements in sleep that last greater than 0.5 seconds.

Total sleep time: Total time asleep.

WASO: Wakefulness after sleep onset.

WNL: Within normal limits.

[StillAnotherGuest]

Well, we could stick a catheter up your nose and down your throat and do another sleep study and get a definitive diagnosis of UARS, or we could give you a 30 day trial with an auto PAP machine and if that cures your symptoms, we'll say it's almost certain you do have UARS. The auto PAP is cheaper and less painful.

LOL! That would have convinced me too!

But if he's using Guilleminault criteria, where the female RDI (AHI plus RERA) was lower than the more traditional accepted value (a mean value of 8.4 vs 15), I'm suggesting that the Guilleminault testing criteria should also be used.

On the other hand, other methodology could also be used (RIP belts, suprasternal pressure transducer, pulse transit times and/or cyclic alternating pattern) that wouldn't make you blow your cookies, and still provide the additional support necessary to make the diagnosis of UARS. Basing the diagnosis simply by looking at the diagnostic pressure waveform is a bit of a stretch.

Course, on the other, other hand (which brings us back to the original hand) maybe he did use one or more of the other methodologies.

But were pressure transducers, in fact, being utilized? When you said

A flow limitation being any reduction in airflow of any amount that led to neither arousal nor desaturation.

That is not exactly correct, it is more accurate to include that the waveform shape changes from a round crest to a more flattened one (see the examples above). Amplitude may or may not drop (that's the point of the IFL1 vs IFL2 discussion), but if the waveform don't get flat, then that's not a FL.

And if the entire night of PSG, including wake, has a FL appearance, well then Houston, we have a problem.

Hey, if you really want to crank him up, ask him to print up some examples of the PSG documenting the FL. Get 5 minute blocks so we can get a good overall look.

The symptoms plus the PSG results of borderline AHI and RDI and the FLs led to the diagnosis which was confirmed by the APAP results.

By "confirmed", do you mean that your symptoms are relieved, at least to some extent?
SAG

[Guest]

Sounds to me you need to find an acredited sleep lab, one that conforms to the quidelines established by AASM/ABSM, because what you quoted above is not according to those guidelines. The only thing missing from your posts so far is your sleep doctor has financial interest in the Sleep Center, then that would explain everything.

Frankly, I resent the implication that I'm an idiot who doesn't know how to verify these things.

My sleep center IS accredited by the AASM (recently so, in fact, so they're more strictly monitored than most) and it's a hospital sleep center, and the entire health system of which the hospital (and my doctor, who IS board-certified in sleep medicine) are a part are non-profits. So neither my doctor nor anyone else has a financial interest in it.

[Guest]

But were pressure transducers, in fact, being utilized? When you said

Are those the two tubes that go under my nose? I had two tubes under my nose, two disc things on each leg, two on my collarbones, one under my ribs, a bunch on my face and head, a snore microphone, and a pulse oximeter. I think that's all.

And if the entire night of PSG, including wake, has a FL appearance, well then Houston, we have a problem.

Well, obviously. No, only the bits where I'm asleep look funky.

Hey, if you really want to crank him up, ask him to print up some examples of the PSG documenting the FL. Get 5 minute blocks so we can get a good overall look.

I've seen the entire thing in 30-second frames. He spent an hour going over it with me frame by frame.

By "confirmed", do you mean that your symptoms are relieved, at least to some extent?

'Zackly. And since my range was 6-9 but my 90% pressure was 7.5, obviously (1) I was having events and (2) the CPAP was alleviating them.

[Guest]

But were pressure transducers, in fact, being utilized? When you said

Are those the two tubes that go under my nose? I had two tubes under my nose, two disc things on each leg, two on my collarbones, one under my ribs, a bunch on my face and head, a snore microphone, and a pulse oximeter. I think that's all.

And if the entire night of PSG, including wake, has a FL appearance, well then Houston, we have a problem.

Well, obviously. No, only the bits where I'm asleep look funky.

Hey, if you really want to crank him up, ask him to print up some examples of the PSG documenting the FL. Get 5 minute blocks so we can get a good overall look.

I've seen the entire thing in 30-second frames. He spent an hour going over it with me frame by frame.

By "confirmed", do you mean that your symptoms are relieved, at least to some extent?

'Zackly. And since my range was 6-9 but my 90% pressure was 7.5, obviously (1) I was having events and (2) the CPAP was alleviating them. I'll ask for a printout of the report from the DME when I have my follow-up next week (he wanted me to get the machine first then schedule a follow up).

[Joethespy]

There have been lots of variances over the years for what determines an hypopnea but the current standard is a 30 to 90 percent reduction in airflow with an associated 4 percent desaturation. The minimum duration of the event must be 10 seconds. A RERA with have the same reduction in airflow and an arousal but the desaturation will not meet the 4 percent criteria.

This is a fairly recent industry change (2003, I think). Previously it was recognized that the two factors that make a respiratory event significant were the desaturation (3 or 4 % at that time) and the arousal. As long as one or the other was associated with the event is should be scored.

I do not fully agree with the new standard because I feel that arousals are significant and should be treated if they reach significant numbers.

Thanks...Joe

[muld00n]

[quote="Snoredog]
DEFINITIONS:
APNEA = cessation of airflow for 10 seconds or greater.
HYPOPNEA =>50% decrease in airflow for 10 seconds or greater with a decrease in oxygen saturation of >3%.
APNEA/HYPOPNEA INDEX (AHI) = apnea plus (+) HYPOPNEA/hour of sleep.
RESPIRATORY AROUSAL INDEX (RAI) = AHI +snoring related EEG arousals/hour of sleep.
AHI/RAI** Scale =<5 events /hour = (none); 5-15 events/hour = (mild); 15-30 events/hour = (moderate); >30 events/hour = (severe).
Respiratory related sleep fragmentation: Sleep arousals due to respiratory events or snoring.
Desaturation = Drop in O2 oximetry distribution saturation by 3% below average saturation.
SaO2 scale: >89%=(none); 85-89%=(mild);80-84%=(moderate); <80% (severe).
EPWORTH SLEEPINESS SCALE =<10=(does not indicate EDS (Excessive Daytime Somnolence));10-15=(indicates daytime somnolence-not excessive);>16 (indicates EDS).
RESPIRATORY EFFORT RELATED AROUSALS (RERAs)=Sleep Arousals due to respiratory events characterized by pressure flow limitations in the airflow indicator channel without significant O2 desaturations.
StageIII and StageIV are combined and referred to as Deep Sleep.
Sleep Efficiency = Normal is >80%
As established by AASM/ABSM 1999.

Normal Sleep Architecture:
Stage1: 5%
Stage2: 50%
Stage3: 10%
Stage4: 10%
Stage REM: 25%

Stage3&4, REM decrease as we age.


Stuff seen on a PSG Report:

Arousal: An interruption of sleep lasting greater than 3 seconds.

BR Arousal index: The number of breathing related arousals(apnea, hypopnea, snoring & RERAs)multiplied by the # hours of sleep.

Bruxism: Grinding of the teeth.

Central apnea: A respiratory episode where there is no airflow and no effort to breathe lasting greater than 10 seconds.

EEG/EOG: Comments about sleep stages, brain waves (EEG), or eye movements (EOG)

EKG/ECG: Comments about heart rate, abnormal heart beats, etc.

EMG: Comments about leg movements and or teeth grinding (bruxism).

Hypopnea: A respiratory episode where there is partial obstruction of the airway lasting greater than 10 seconds. Also called partial apnea or hypo-apnea.

Non-supine: Sleeping in any position other than on the back.

NSR: Normal sinus rhythm.

NPSG: Nocturnal Polysomnogram, or sleep study.

(#)Number of Awakenings: The number of pages scored as wake after sleep onset.

Obstructive apnea: A respiratory episode where there is a complete cessation of airflow lasting greater than 10 seconds.
PLMs: Periodic limb movements.

PLM arousal index: The number of periodic limb movements that cause arousals multiplied by the number of hours of sleep.

PSGT: Polysomnographic technologist.

REM latency: Latency to REM(dreaming) from sleep onset.

RERAs: Respiratory effort related arousals. Episodes that are not apneas or hypopneas, often related to loud snoring, that generally do not cause a decrease in oxygen saturation.

Respiratory: Any specific comments about respiratory events.

RPSGT: Registered polysomnographic technologist.

Sleep efficiency: Total sleep time multiplied by time in bed.

Sleep latency: The first 30 seconds (one `epoch' of recording time) of sleep.

Sleep onset: The first 90 seconds (3 `epochs) of uninterrupted sleep.

Sleep stage shifts: The number of incidents of sleep stage changes.

Snoring intensity: Level of snoring loudness determined by the sleep technologist. Ranging in degrees from mild to very loud snoring.

Spontaneous arousal index: The number of spontaneous arousals (e.g. arousals not related to respiratory events, limb movements, snoring, etc) multiplied by the number of hours of sleep.

Stage 1: The lightest stage of sleep. Transitional stage from wake. top

Stage 1 shifts: The number of times the sleep stage changed to stage 1.

Stage 2: The first true stage of sleep.

Stages 3/4: The deepest, most restorative sleep.

Stage REM: The dreaming stage; Normally occurs every 60-90 minutes.

Supine: Sleeping on back.

Time in bed: The time in the study from `Lights Out' to `Lights On'.

Total arousal index: Total number of all arousals multiplied by the number of hours of sleep.

Total # of PLMs: The number of leg movements in sleep that last greater than 0.5 seconds.

Total sleep time: Total time asleep.

WASO: Wakefulness after sleep onset.

WNL: Within normal limits.
[/quote]

Snoredog, I found these definitions to be very useful and helpful; thanks for posting them. I think it would be a good idea to include these somewhere in either the "Our Collective Wisdom" area or the FAQ area.

Would it be possible to get them created there for everyone to reference?

Steve

[StillAnotherGuest]

This is a fairly recent industry change (2003, I think)

The new scoring standards and manual came out last month, you can get it from the AASM.
SAG