MSLT Fail Not Fair

[Julie]

Just to be picky here , apnea doesn't get 'cured', only managed, like e.g. diabetes... however technology is changing very fast lately and it's quite possible that there will be other ways to deal with it besides Cpap in future. There are other options now, but none have been shown to be much good and some cause worse problems afterward.

[TorontoJewel]

thanx for your input Krelvin. Yes I feel that our degree of stress and activity, as well as pain greatly effects our ability to daytime sleep.

[robysue]

apnea & Hypopnea index of 12.8 hours of sleep
Rem & Supine AHI 16.1 & 18.1
73 Respiratory arousals with respiratory arousal index of 12 per hour of sleep
Oxygen saturation minimum was 91% with a mean of 96% Awake mean oxygen saturation was 96%
ECG : no cardiac arhythmia was reported
PLMS: No evidence of periodic leg movements
Alpha-intrusions: Yes
MSLT: 4 naps during the day with latencies of 4.5, 0.5, 0.4 and 1.3 minutes. Mean sleep latency was 1.6 minutes. No sleep-onset REM period (SOREMP) was noted.

With the AHI index of 12.8 and REM/supine AHI > 15, it's unusual that they even continued to the MSLT test. In many sleep centers, if OSA is found, they'll cancel the MSLT until the person has been on CPAP for a while to see if treating the OSA clears up any reported excess daytime sleepiness.

Impression:
1. mild sleep apnea, but moderately severe in REM with associated disruptive snoring.
2. some sleep fragmentation due to intervening arousals and awakenings.
3. Reduced amount of REM sleep

This sounds like a very reasonable interpretation of the night time sleep study results. And if you got anything more than 2 hours of fragmented night time sleep (even with the migraine), the OSA, sleep fragmentation, and reduced REM findings are highly likely to be legitimate. The MSLT is used to diagnose narcolepsy, and you will notice that narcolepsy has NOT been diagnosed even though you did fall asleep during each of the nap periods. The likely reason why narcolepsy was NOT diagnosed was that you did NOT reach REM sleep in any of the nap periods.

he is suggesting I have severe daytime sleepiness, and mild sleep apnea with moderate severe apnea during REM, & sleep fragmentation. Didnt bother to tell me any risks to my health until I asked. I rarely take naps at home, the only time I sleep during the day is when I have a migraine, at which point I am in bed for days and I do not drive during this time.

Ok, let's take this one step at a time:

He may be overestimating the daytime sleepiness, but a lot of folks with OSA have problems with daytime sleepiness. But a few of us don't report daytime sleepiness as a major symptom of OSA.

Next: The diagnosis of mild OSA is warranted based on the AHI = 12.8. Mild OSA is diagnosed whenever the overall AHI is between 5 and 15, meaning that on average, the person is experiencing an apnea or a hypopnea once every 4-12 minutes of sleep. In your case, the overall AHI = 12.8, which indicates that you were experiencing an apnea or a hypopnea about every 5 minutes so so (on average) when you were actually asleep during the night time portion of your sleep test. And each of those apneas and hypopneas cause a respiratory related arousal, wake, and/or sleep fragmentation, and all the respiratory arousals/wakes and sleep fragmentation lead to the feeling of non-restorative sleep, which you DID report as a major symptom that lead to the sleep test in the first place.

Next: The diagnosis of "moderate severe apnea during REM" is perhaps a bit extreme, but a REM AHI of 16.1 is high enough to warrant a diagnosis of MODERATE OSA during REM. And it's also high enough to explain a reduced amount of REM sleep as well.

Finally: The detection of alpha intrustions is also significant and warrants a discussion with the doc. I have no idea if the migraine is enough to explain the alpha intrusions or not. (Alpha intrusions can be related to pain, however, and so it's possible that the alpha intrusions are being considered as likely caused by the migraine.)

Recommendations:
1. In view of MSLT results, CPAP trial recommended
2. Behavioral modifications positional therapy
3. advise patient about risks of driving motor vehicle and/or operating heavy machinery when feeling sleepy.
4. patient will be seen in follow up to discuss the sleep study results and treatment recomendations.

The only thing that's strange here is the language that reads "In view of MSLT results ...". Your diagnostic AHI is high enough that a CPAP trial would be routinely recommended here in the states without doing an MSLT. Indeed, your AHI is high enough where most US sleep centers would have simply canceled the MSLT and sent you home at 6:00AM with a diagnosis of OSA and a recommendation to try CPAP.

Positional therapy may be an option if you spend a lot of time sleeping on your back, but you will need to find out what the implications are in terms of demonstrating "compliance with OSA treatment" to the ministry in charge of drivers licenses.

All patients who are diagnoses with OSA get the standard warning about the risks of driving motor vehicles with untreated OSA. And there is a reason why: Many (not all) people with even mild OSA do have excessive daytime sleepiness and some of those people are unaware of just how sleepy they are during the daytime. And investigations into crashes that are attributed to the driver falling asleep at the wheel often uncover evidence that the driver had untreated OSA at the time of the accident.

So you're not being "picked" on by your doc when he stressed that driving with untreated OSA is a risky behavior.

I don't agree with the MSLT. I argued that I had a migraine, took meds, was woke up at 5:45 am, and of course I was tired. I don't feel 6 hrs sleep was enough but the doctor did. He seemed quite angered that I was questioning the test and told me normal people don't sleep in the day after sleeping at night then he asked me if I drive and showed me a paper they send to the ministry for non compliance of CPAP.

It sounds like you and the doc were talking past each other.

The OSA diagnosis is UNRELATED to the MSLT results. And the threatened letter to the ministry about non-compliance with CPAP is based on the overnight sleep study results that show the existence of OSA at a mild-to-moderate range. And the OSA was diangosed on the night time portion of the test and it only requires 2 hours of fragmented sleep during the 6 hour sleep period for the test to be considered valid.

But it's clear that the doc did not do a very good job of explaining why the OSA was diagnosed, why the existence of the migraine probably has no bearing on the validity of the night time portion of your sleep test, what the risks of untreated OSA are, or how CPAP is supposed to help in your situation. In reading between the lines of what you've written, it may also be that the doc was using the sleep latencies on the nap portions of the MSLT to try to get you to admit to experiencing excessive daytime sleepiness, which was clearly evident on this day. But he was not doing a particularly good job of listening to you and your reports of why the obvious daytime sleepiness on this particular day could easily be explained in terms of the migraine and the excessively early wake up time.

Can I get a second opinion? Is this guy going to notify the ministry ? I've been driving my whole life, never fall asleep at the wheel, never had an accident. He told me that if I get into an accident I may not be covered by insurance because of the results of my MSLT.

These are significant legal questions you are asking about. You may want to contact your car insurance about whether or not an accident would or would not be covered if you were found at fault because you did fall asleep at the wheel after an OSA diagnosis and you were not using a CPAP.

As for getting a second opinion: In the US, the answer would be, "Yes, you can get a second opinion and most likely your insurance would even pay for it." In Canada? I'm not at all sure how your government-subsidized health care system works. So that's a question for the paper-pushers in the appropriate government office.

Such bullshit. I don't want to go back for the followup but apparently theres an sd card in the CPAP that records everything. Can I argue the results of the MSLT based on my migraine? Has anyone else been treated this way after a study?

In my opinion, you have enough reasons to be upset about the way this guy treated you to file a formal complaint and ask for a referral to a different sleep doc if necessary. But I would NOT be fearful of the follow0up appointment because there is an SD card in your CPAP. The SD card will prove that you are using the machine every night as directed as long as you use the machine. And if you are using the machine to treat the OSA, then you will NOT lose your driver's license.

And if you can figure out a way to avoid getting another migraine on the night of the follow-up test, you should do just fine on any follow-up MSLT test that is scheduled. And that should be the end of your problems.

Was told to go across the hall and pick up my CPAP which I did. I've been using it for the past week and have to go back to the doc to hand in the results and go for another sleep study. I'm scared now. I don't want to go to sleep during the study because I'm afraid of my drivers license being taken. I don't know if this doctor was trying to scare me into getting the machine or what...are these thier usual tactics? Im Canadian

I am NOT Canadian and so I really can't answer the questions about the legality of the threat about your driver's license. I'll offer this observation, however: If you are NOT compliant with CPAP and you refuse



apnea & Hypopnea index of 12.8 hours of sleep
Rem & Supine AHI 16.1 & 18.1
73 Respiratory arousals with respiratory arousal index of 12 per hour of sleep
Oxygen saturation minimum was 91% with a mean of 96% Awake mean oxygen saturation was 96%
ECG : no cardiac arhythmia was reported
PLMS: No evidence of periodic leg movements
Alpha-intrusions: Yes
MSLT: 4 naps during the day with latencies of 4.5, 0.5, 0.4 and 1.3 minutes. Mean sleep latency was 1.6 minutes. No sleep-onset REM period (SOREMP) was noted.

Impression:
1. mild sleep apnea, but moderately severe in REM with associated disruptive snoring.
2. some sleep fragmentation due to intervening arousals and awakenings.
3. Reduced amount of REM sleep

[TorontoJewel]

Thankyou so much RobySue for your extensive reply. Very informative. Yes he was not very good at explaining at all (imo). I wasn't aware that everyone is told about their drivers license that gets diagnosed with this, so that makes me feel better. Perhaps he was rather stern from the beginning to make sure I'm scared enough to follow through with treatment. (although I would follow through anyway)

I'm using the machine 4 days now and my AHI is 3.1 If my results state I'm averaging AHI 12.8 without the machine, then I would assume it is significantly helping whatever condition I was unaware that I had in the first place.

[TorontoJewel]

Questioningly (running out of Introductory Adverbs), what was your Epworth Sleepiness Scale prior to testing?

I dont think it was anymore than 4. They gave me a bunch of papers to fill out with the epworth questions after the sleep study. I only answered two questions with slight fall asleep and moderately fall asleep.

[Sludge]

With the AHI index of 12.8 and REM/supine AHI > 15, it's unusual that they even continued to the MSLT test.

Not necessarily. I believe in general, the cut-off for cancelling MSLT is generally AHI>20 during diagnostic NPSG, because (among other reasons) CPAP may not even be covered for mild OSA (AHI 5-15) unless additional symptoms (like EDS) are present (and with ESS at 4, there was no EDS)(except now we're dealing with an MSLT that "objectively" (HAHAHAHAHA) demonstrates pathological sleepiness)(but you can't base an MSLT on 20-20 hindsight).

BTW, since ESS was 4, what were the indications to do MSLT in the first place?

[Sludge]

I'm using the machine 4 days now and my AHI is 3.1 If my results state I'm averaging AHI 12.8 without the machine, then I would assume it is significantly helping whatever condition I was unaware that I had in the first place.

What's your ESS now?

[Sludge]

Can you clarify exactly what this breakdown is (apneas. hypopneas and RERAs)?

The only breakdown on the paper is that the longest apnea 25.0 seconds, longest hypopnea 40.0 seconds

Since you have a lot of reasons to have very disturbed sleep, it will also be important to find out how many of those events were central (especially post-arousal central).

If it turns out your obstructive AHI is <5, then this entire endeavor needs a whole lot of rethinking.