Odd comment from my Pulmonologist

[SuperChild]

I was in recently for a meeting with my new pulmonologist. The old one retired earlier this year, I needed a new script for a machine and supplies.

He looked over my sleep study results from 2013 and asked me why I was on CPAP given that my AHI was 7.2

244C7BCE-27D6-4CC8-BB82-9FF71E73F79D.jpeg (221.15 KiB) Viewed 2153 times

My face
I can’t imagine that if I wasn’t supposed to be on CPAP, someone would have mentioned it, right?

Edited to add: I know the cutoff for a diagnosis of sleep apnea is an AHI of 5. Since 7.2 is greater than 5…

[Pugsy]

Some docs don't think an AHI of 7.2 warrants cpap.
Sounds like this new doc is one of them.
Some insurance companies don't either unless there are other co-morbidities going on as well.
Other factors that might tip the scale...high blood pressure, excessive sleepiness, desats, headaches, fatigue, etc.

[SuperChild]

Ahhh! Thanks Pugsy.
He was younger-ish. Probably early 50’s. The one he replaced was older and I think had more experience with critical care (not that I needed it).
Well, the important thing is I got that new machine (PR DreamStation)…just in time for a recall a few months later. Glad I kept the ResMed S9 as a backup!

Side rant: my wife has the S10 or whatever it’s called. I have never had more problems with a machine leaking. At least I think the tank leaks every so often and I periodically have to jostle the thing around on the table because it will stop drawing enough air in. Drives me batty! But it looks good and takes up more of our money for supplies vs the S9.

[kteague]

That partial report leaves a lot unsaid. Were the references to first and second half of the study because it was a split study? I'm not used to seeing a split study referred to like this with numbers given for the whole night, nor a full night diagnostic study defined by halves. But then again, can't say I've seen all that many reports. My own split study long ago calculated the diagnostic and titration portions separately. Since it is common for breathing events to be worse in REM, a study with little REM sleep, as well as REM while supine, may not fully appreciate one's worst case scenario. A doctor should consider that when a patient appears to have a near borderline result. My doctor called those studies "technically sub-optimal" and leaves room for the possibility the numbers could have been more. Also, I see you had limb movements. Were they deemed respiratory related? If not, there's always a possibility those can cause an unreliable result. Did your limb movements cause any arousals? Limb movements can mask apneas and apnea events can mask limb movements. Even without more information I think I agree with your first doctor about CPAP. If you had no limb movements outside respiratory related and had significant REM while supine, I might feel different. Then I might have wondered if positional therapy would suffice. btw, did your limb movements resolve with CPAP use?

[SuperChild]

Hi, it was a split night study. I don’t recall if the limb movements improved with CPAP use. I know I am much more rested and don’t snore nearly as bad though when I am on it, so there’s that.

[Morgoth]

Hmmm,

I had a similar-ish experience.

15 years ago I was noon napping at my moms, who is a nurse, and she noticed beside my mega loud snores that I'm elevating my chest trying to catch a breath and that I don't breathe for some time, she was genuinely frightened, and since sleep apnea wasn't a known thing in my country, she ordered over-night EKG or whatever is called to track my heart while sleeping, and they said everything was fine... I was 20 years old back then.

But in coming years I developed heavy sleeping problems, I can't connect more than 3-4 hours in sleep, 5 at max when I am really exhausted, and while I did was a bit inactive during this pandemic, I used to workout daily, both gym lifting and playing basketball, basically almost everyday something, so it's not like I wasn't sleeping well because I wasn't active or something...

So, as time was passing, I had more and more sleepless nights, like I would fall asleep , wake up once or twice, and I can't sleep any more, to the point that going to sleep became a nightmare for me and everyone around me, because I was exhausted all the time, nobody believed me I had a problem everybody thought I was just spoiled, since my job is not 9-5 and I'm working in music industry in this part of Europe... Just to mention I wasn't using anything, I don't even drink alcohol, not even beer...

So two years ago after I connected like 3-4 days without sleep and 10 days with 3-4 hours sleep per night max, I noticed my pulse got elevated like resting 90-100 and I tried to get some help. I found a doc that is doing in home sleep studies, and went to see him. Given that I have chronic rhinitis and chronic bronchitis and all other symptoms like snoring etc, he was positive that I had sleep apnea etc... So he came to my house, wired me up and left... I got so anxious because I knew I had to sleep, and I couldn't fell asleep, I was lying down, frozen, trying not to move etc... I called him in the morning and told him "Doc, I wasn't sleeping", he was like "Nah okay, if you wasn't sleeping we will do it again"...

So, I went to play basketball and he called me while I was on the court, I answered and he was like "Hey, I'm so happy I hear you are active, and that you are doing sport, listen, you weren't sleeping almost at all, but I caught 20 minutes of sleep, and your AHI was 14.9, that's a mild apnea, that's not for the treatment, I would say you are just a bit more nervous guy and that's all...You don't even snore" Lol, I don't know what the hell he caught, since he didn't detect any snoring, I'm a literary a demon from hell when it comes to snoring, I bark like a dog, but whatever he caught, it was AHI - 14.9 and he thought it wasn't for treatment and sent me to a shrink. Also, he didn't want to repeat the study...

So a psychiatrist put me on beta blockers and zoloft, and I started to fall down asleep a bit easier, but I was still waking up with racing heart etc, not to mention snoring... Was recording myself with snorelab, I'm constantly hitting EPIC, and I don't stop at all, I don't have any quiet passages except when I don't breathe at all, those are quiet...

Fast forward 2 years (this year), my wife and I moved to another town, again I connected 5-6 days of not sleeping, and decided to do a sleep study here. And voila, I succeed to catch 4-5 hours of sleep while hooked up, and the result AHI-41, O2 saturation 71%, and finally got prescription so I can even buy a CPAP, and I got a damn DS1, and foamgate occured 5 days after I got it....

Basically God knows how much damage I did to my body and heart and everything else during this 15-20 years of untreated OSA, and also I had a doctor who caught AHI-14.9 in 20 minutes while I was trying to fall asleep, and he thought it wasn't for treatment yet...

[SuperChild]

I know this is reeeeally old.

I was a preemie. Like 26 weeker in 1979.
I assume most preemies have apnea issues when they’re still in NICU, but I wonder if that may have been a cause for me to develop apnea. Or a reason why they diagnosed me when it was only 7.2.

Mom said that one of the worst sounds was the (apnea???) alarm going off. As a grade schooler, she’d still pop by my room at night. I know it was to make sure I’d gone to bed and wasn’t up reading, but I also wonder if she’s ever stopped worrying.

[chunkyfrog]

7.2 is still lousy.
You may have comorbidities.
If insurance covered your equipment, trust that they would not have done so
if it were not medically necessary.
Lose the knucklehead doctor--you don't need a paid nincompoop.

[dataq1]

As this was a split study (part of study conducted with trial PAP pressures), the 7.2 AHI ought to have been calculated during the untreated (no mask-no Pap) time period. What is confusing is the remark: "Abnormal breathing events tend to be most pronounced ... and FREQUENT during the last half of the study".

Is the "last half of the study" during the "last half" of the untreated period, or does the "last half" refer to the titration segment of the study? Does your "new" pulmonologist know?

It would seem that he is questioning the original sleep study, and that's appropriate, because it's unclear. With a marginal AHI and a unclear sleep study, it makes sense that a (mildly) curious physician would ask.

Personally, I would say that IF I had a 7.2 AHI night after night after night that therapy is called for. On the otherhand, if the 7.2 AHI was the result of a single 4 hour slice of your life, AND it's not representative of your "normal" breathing pattern, AND if there are no other sleep disturbance symptoms, then a reassessment might be in order.

[D.H.]

I agree, 7.5 is enough for CPAP. They say that five is the cutoff, but I think that's too high.

You've been using CPAP for a prolonged amount of time (long enough to need a replacement machine). Therefore, doctors and insurers should not second-guess the original prescribers and the patients.

It's very hard to persuade new patients to comply. It should not be hard for compliant patients to access therapy!

BTW, is the doctor who bought the practice from your retired doctor?

[lazarus]

My thought on original old post:

Seems to me the doc's "comment" was more of a question. When a doc asks a question, it is often meant to get more information, which is a good thing. So just answer it: "I had such-and-such symptoms/comorbidities."

Patients with severe SDB (respiratory disturbance index [RDI] >20-30) should be treated irrespective of their symptoms . . . Patients with an RDI of 5-20 should be treated if they have symptoms or coexistent cardiovascular disease. . . . Medicare guidelines specify . . . patients with an apnea-hypopnea index (AHI) greater than 15 are considered eligible for CPAP, regardless of symptomatology. For patients with an AHI of 5-14.9, CPAP is indicated only if the patient has one of the following: excessive daytime sleepiness (EDS), hypertension, or cardiovascular disease.

https://emedicine.medscape.com/article/295807

[chunkyfrog]

Cpap turned my life around, and my non-treated AHI was only 13.
With HBP and diabetes, cpap was (almost) a no-brainer.

Q: What do you call the guy who graduates at the very bottom
of his class at medical school?
A: Doctor.

[Miss Emerita]

I know I am much more rested and don’t snore nearly as bad though when I am on it, so there’s that.

I hope you told the new doctor exactly this.