Hi, folks! My partner has very severe sleep apnea, so bad that the first time we slept in the same room, I was all, "Um, yeah, guess what, you have sleep apnea." So when I went to an ENT doc with headaches and he ordered a sleep study, I was pretty sure I didn't have it.

The sleep lab begs to differ... They claim that these hypopneas are enough to merit a CPAP. Only thing is, I don't have excessive sleepiness (when I don't stay up late, which I usually do, but that's because I enjoy chatting on the computer late at night). If I have slept a normal amount like a good girl, I do NOT doze while doing things that require little attention like reading or watching TV, let alone while in public places or driving! I have never fallen asleep in a public place or while driving, ever.

I'm pretty sure my headaches are sinus-based. Why? They are behind the eyes and cheekbones; I had a somewhat-but-not-terribly-bad-looking sinus CT scan; they are worse when I am exposed to allergens; they get worse when I am horizontal or bend over; decongestants help somewhat; allergy meds have reduced their severity and frequency; and I got a few short-lived headaches of this type when I got up from corpse pose in yoga class, when I should have been breathing extremely well.

The oxygen saturation on here is alarming, but also I'm wondering how much of an effect the sleep lab environment can have. Also, just before I went to the sleep lab I had been poking inside a dusty computer CPU for a friend, and I am very allergic to dust. That was dumb.

Labwise: An electrode glued to your throat with a cord that wraps around half your neck feels kind of chokey, leaving aside all the other junk they had glued to me; it was hot in there, and I was wearing way more clothes than I usually sleep in; I almost always sleep on my side and of course I had to sleep on my back as much as possible for this; the phone kept ringing and waking me up, and some guy came in really late to have something done, and he was not quiet about it. He had demands. It claims a sleep latency of only 25 minutes, but I know it took me longer to really fall asleep. It took a lot of conscious effort to relax and block out the noise and picture myself on a beach and whatnot; 25 minutes in may have been when I first dozed, which makes me think that 180 arousals is bogus.

Frankly, the sleep lab sleep was the worst sleep ever. I felt like something the cat dragged in when they woke me up. If they titrate you in the same conditions, wouldn't that inflate the setting you need?

So, anyway...given all that, and the hypopneas-only nature of my results, would you get a CPAP? I have years of experience watching my partner use one. It made a HUGE difference for him, a lifesaving difference, but it's a big hassle too, and I don't want one if it's not going to help me. I also don't want one if it's going to distract my ENT from fixing my expletive-deleted sinuses.

Anyway, here are my results. Can anyone explain what MVNT means, by the way?


Study Date: 7/27/06

Sex:    F
Age:    30
Height: 5'7"
Weight: 287

Total Recording Time (TRT): 418.3 min.
Total Sleep Time (TST): 352.9 min.
Sleep Efficiency: 84.3 %

Sleep latency:                25 min
REM latency:                  174.5 min
Resp. Arousals > 15 Seconds:  180

STAGE       Minutes     % of Test
  I         39.5        11.2
  II        188.5       53.4
  III/IV    90.9        25.8
  REM       34.0        9.6
  MVNT      0.0         --



                       APNEAS               HYPOPNEA    Apnea & Hypopnea
                                                     Events          Events
                          C    O    Mixed
Index:                 0    0     0           31.1           31.1
Mean dur (sec):                             24.4           24.4
Longest dur (sec):                          34.7           34.7
REM Index:          0    0     0           24.7           24.7





Snore Events Summary:
                  REM       Non-REM       Total
Snore Events
   Number:        0         59            59
   Index:         0         11.1          10.0
Snore Arousals
  Number:         0         0             0
  Index:          0         0             0


PLM Events Summary:
No PLM events

APNEA AND HYPOPNEA INDEX
REM Stage RDI:     24.7
RDI:               31.1

OXYGEN SATURATION
Mean Sa02 %: 93.1
Min. SaO2%: 87.0

INTERPRETATION: Moderate obstructive sleep apnea. (2.2 minute=SaO2< 90.0%).

RECOMMENDATIONS: Overnight sleep study with CPAP titration.

Oh, not really relevant but interesting: I do sometimes snore, but I also sometimes moan in my sleep, which is an exhalation thing, and harmless except for creeping out my freshman year roommate. (Catathrenia! Woot!) Do you guys think the computers can generally tell the difference, or could that 59-snores number be wrong too?

And so yet another pesron with only hypopneas.  I really wish we had some info on this.  The "party line" is that hypos are as bad apnea.  I have had little luck searching for hypopnea info because searching online almost always gets a match that inlcudes apnea, the two being grouped together.  Further, the definition of hypopnea is vague.

I have the same concern that you do, that perhaps hypops are a red-herring (which seems possible under certain definitions of hypopnea).  On the other hand they could be UARS-type events.

BTW I also had a sleep latency that was short (8 minutes).  But latency to 10 minutes of sustained sleep was closer to 50 minutes in both of my studies.  I think this mirrors the effect you were experiencing... and is a result of SDB waking you up as you are drifting off.  


Incidentally your sinus problems and apnea diagnosis could be related.  Stuffy sinuses could mean you're breathing worse - no real surprise there.

I have, after discovering the article yesterday regarding the prevelance of SDB, been doing some research into possible other causes and effects of apnea.  I have found that, most notably, apnea and insulin resistance are correlated and apnea independently causes insulin resistance; http://ajrccm.atsjournals.org/cgi/content/abstract/165/5/670 (among countless others).

Anyway the significance of this is that, even without a CNS hypersomnolence effect, there can be significant health consequences. - at least in my non-professional opinion.

Or in other words, even if you are not sleepy, you should still look into getting CPAP, as it is important to your overall health

Have you been gaining weight recently?  Given your very high (no offense) BMI....  this is quite possibly a cause for apnea that you have not experienced before.

Thanks for the reply!

No offense taken, but actually my weight is pretty stable. If anything I've been slowly (very slowly) losing, not gaining, from a high of 312 a few years ago. Also, my primary care doc did EXTREMELY complete lab work on me. I do not have insulin resistance, my cholesterol is nigh-on perfect, and I don't have high blood pressure or weird hormones or anything else out of the ordinary.

Do you have links on UARS? I keep seing that mentioned but I can't find much info on it.

This report didn't tell me the latency to sustained sleep. If I asked for the raw data, do you think I would be able to make anything of it without having the software? (I love data. I'm a database administrator.)

The problem with the raw data is that you'd have to represent it visually... it's possible, I guess, to analyze it to *some* degree...

But what you really want is one of those super cool sleep-stage graphs.  SleepyDave will be asking about them when/if he gets to this post, I'm sure.  It's possible they were generated for the doc, and just not sent to you, so you might be able to sidestep going through 8 hours worth of wave tracings.  

I'm also curious if your sleep staging was related to position.  Your architecture is fairly good. - 25% SWS and 10% REM.  That seems to me to imply that your sleep isn't all that bad...  but if you were doing terrible in a given position, that would be meaningful info.

UARS is another minefield of a subject because there is significant debate regarding the subject.  Or there was.  I've ranted on it before; most of the non-scientific literature seems to be content to just say "UARS exists on the spectrum between Apnea and snoring", as though it's apnea light.

What it is in essence is the brain detecting increased respiratory resistance and causing arousal before flow reduction becomes significant.  
http://www.chestjournal.org/cgi/content/full/115/4/1127

The problem with the diagnosis is that it can be almost impossible without putting sensors down the patients throat to measure the pressure buildup there - not something that is usually done (or practical).  As a result as recently as 2000, there was debate whether it even existed:
http://ajrccm.atsjournals.org/cgi/content/full/161/5/1412
http://ajrccm.atsjournals.org/cgi/content/full/161/5/1413

were actually published side-by-side!  Obviously one of those papers seems to think UARS should be considered separately, a position which I adamantly support.  It was that paper which led me to visit a sleep lab - UARS sounds a lot more "like me".

Of course those that would argue that UARS is not distinct do posit that hypops are really the same as UARS:

"Major diagnostic confusion about UARS centers on the scoring of hypopneas (...) Those centers that use these methods to define hypopneas rarely, if ever, classify patients as having UARS, whereas centers that rely on thermal definitions report UARS frequently"

Interesting, no?  this has led to me grouping hypop-only and UARS patients together as one group, which tend to have common -- and different - symptoms.  For instance, insomnia.  I think the failure to recognize the symptoms of UARS separately creates a lot of unterated patients, though.  Insomnia can in some cases cause you to "fail" the ESS, because if you can't sleep... you can't possibly be sleepy.   This is one of the main reasons I despise the ESS.

But what does this mean for patients?  That's the answer I don't have at this time, and have been seeking desperately.  The literature on hypopneas is sparse, largely because it's hard to untangle from apnea:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=3354998&dopt=Citation
suggests, "Patients with recurrent hypopneas were clinically indistinguishable from and had a similar frequency of 4% desaturations (zero to 104/h) and arousals (7 to 98/h) to the patients with frequent apneas. This study confirms that hypopneas are clinically important and that the "sleep apnea syndrome" may occur in the absence of recurrent apneas."  

Apparently after this study, regardless of knowledge gained from UARS, it is accepted as a truth that hypopnea=apnea clinically.

Clearly something doesn't add up here.  We have one camp arguing that UARS is different from Apnea, with different symptoms, a second claiming that UARS is apnea lite and UARS events are often really hypopnea events, and a third that hypopnea and apnea are the same.  All of these things cannot be true, as they say UARS != Apnea, UARS=Hypopnea, and Hypopnea=Apnea.

Anyway that's my spiel on UARS...  I am rather upset with the current state of both doctor and patient education on the matter.  I wish somebody would take the time to discuss them beyond defining them vaguely and then announcing them to be on a spectrum (the spectrum usually being Apnea>Hypopnea>UARS>Snoring>Normal Breathing).

Here is how I define UARS, if the patient is snoring and there is a restriction in either airflow or change in respiratory effort with an increase in EEG frequency then it is an UARS. Sleep that is interpupted is just as significant health wise as drops in O2 sats and apneas and hypopneas. However getting insurance to agree to this is the difficulty. The other difficulty is the way that we measure changes in breating and respiratory effort. If a sleep lab is using an epezo sensor to measure respiratory effort all that are doing is measuring the movement of your chest and abdomen during the study, Thebetter way is to use some form of pleismography, which measures total expansion of the chest and abdomen, better but agian not ideal, the best way would be to measure muscle activity again not an easy thing to do, also a thermister used to measure breathing is not measuring airflow at all but measuring changes in heat, it works on the premis that the air that you breath out is warmer than the air you breath is and is hardly qualitative. The better labs will use a nasal pressure transducer, this does measure pressure changes, however it works best with patients that are breathing through their nose, some have cannula that do measure oral breathing but this is not as good as the nasal airlfow. The best solution is to use a eosophageal balloon. However this is difficult to inset and not all sleep labs would have the expertise to do so. It is not that confortable for the patient either.
So you can see with different labs using different equipment and some of it with severe limitations in the equipment to say nothing of the staff, it is understandable why definitions are difficult. My best advise is to ONLY go to a AASM accredited sleep center for your sleep evaluation. The AASM also has sleep labs accredited as well only to diagnose sleep apnea, again personally I would not go to one of these when there is an accredited sleep center close by. The reasoning being that very few patients have just simple sleep apnea and it is better to have a full analysis of your sleep done and not just sleep breathing.


_________________
Iain Boyle MS, MLT(CSMLS), RPSGT

FYI my sleep center is AASM certified.  The sleep report bears their Yin/Yang logo... and actually it was one of the first to be accredited according to what I have found.

Anyway today is my day for CPAP!  I will report back to this forum (on one board or another) with the results.  I have been anticipating this day for so long... can this really be the end of my sleeping woes?

IainB - why is snoring a part of your definition of UARS?  I ask because I'm not a snorer - but I have many hypops and related arousals and no desats and am a poster child for the uars type symptoms.  My sleep doc diagnosed me with obstructive sleep apnea, but the uars descriptions fit me more - but i don't snore.

i've had an APAP for a few months and I can only sleep 1 to 4 hours a night on with it - with sleep meds.  that is a major challenge for people with sleep-maintenance insomnia.  my sleep doc said once i started the APAP, i wouldn't be such a light sleeper anymore but alas, it's not the case.

i hope you have better luck sleeplessj and thanks for those links.  jenny

jrgoo you sound quite a lot like me.  I snore mildly at worst, according to my ex; often I don't snore at all.   I remain hopeful that CPAP can kill the arousals and thus the sleep maintenance insomnia.  With ambien, I generally do not have sleep onset insomnia problems.... Actually in both my first and titration studies (both ambien-enhanced) I had my first epoch of sleep in 8-9 minutes,  but it took about 50 before I had my first 10 minutes of sleep.   Of course to me it seemed more that I was staying awake all that time, but it did seem to confirm my hypothesis that falling asleep wasn't my problem, rather, waking up as soon as I did so.  

Anyway, as I suggested... there seem to be a block of people who have only hypopnea events, and from the descriptions I have read, the symptoms are similar to UARS.  If you look at the "UARS is a distinct syndrome" link I posted... it is what led to me getting the CPAP machine I have today.  Not being much of a snorer, and not being fat, apnea never seemed right.  UARS OTOH, sounded a lot like me.

The real problem as I see it is that whether you call it UARS or hypopnea-only OSAHS, it seems to have different symtpoms which are just not being recognized... and leaves some of us wondering if the big shiny expensive machine is going to do anything for us.   I don't see data about it being studied separately.

I hope my doc is right and I don't wind up like you :(.  At my study however, it was found that lower pressures were all but useless... it was only once I got up to 13 that the events really seemed to drop off, though the condensation woke me up and prevented long, good sleep.  What range is your APAP set to?

I'm in kind of a unique situation - my sleep doc didn't want a titration study, but we are using the APAP to titrate.  So I have a wide range. 4 to 18.   My 95% rate hasn't gone above 9 though and usually stays around 6-7.  

There seems to be a wide variation in how hypops are measured which is also confusing to me.  Some definitions rely on a related desat.  But like I said, I had no desats and no snoring during my study and lots of hypopneas and arousals.  So I guess my lab didn't include desats in their definition.  

I wasn't diagnosed for the longest time because i'm younger, not overweight and I made the mistake of saying to the 2 PC docs I saw, 'I'm not sleepy, I'm just exhausted'.  If you're not saying the right words, 'I'm falling asleep at the wheel, etc' - you can't get a diagnosis.  And I even told my last doc that when I fell asleep on my back, my throat closed and it woke me up!  She clearly didn't believe me or thought I was imagining it or something.  I asked her if that was apnea.  And she said no, you don't have apnea.  So I said, so what is that then, if it's not apnea?  And she ignored me.  

It seems each doc I saw would ask each visit, so you have trouble falling asleep? -do you have a lot of stress?  And I would explain, no actually I fall asleep just fine.  I just can't stay asleep.  And the only stress I have is that I can't sleep and I'm in pain most of the time.  No I don't want an antidepressant thanks anyway.

I'm glad you found the UARS research and followed up on it for yourself and I hope you have a lot of success.  I haven't given up hope just yet.  Managed to do 4.5 hours last night with Lunesta.  That's a new record for me.

How familiar jrgoo - as noted I despise the ESS because it only reinforces the "you're not falling asleep at the wheel, there's no apnea".  I used to live in fear that my doc ask me: "Do you snore heavily?  Do you fall asleep inappropriately?" and I would be forced to answer no and be kicked out.  It all gets back to the UARS vs. Apnea thing I mentioned earlier.  

It really helped when I started to define "microsleep" as "falling asleep" - when I sort of nod off and zone out.  I don't think of it as true sleep, but pretending it is really helps you to get around these semantic difficulties.

Docs are looking for the slam dunk patient - 60 yo male, obese, snores like a jackhammer and wife is really getting worried that he stops breathing so long at night.  If you don't fit that profile, you can get dismissed.  Honestly as I (and Guilleminault, et al) noted, the symptoms and epidemiology of UARS are different, whether we want to score it as hypops or what.  Thank goodness the doctors I saw wouldn't dismiss me - I remember being *so* relieved that they asked me "Do you ever feel tired when driving?" and I had to ask them to repeat it...  I had been so worried it would instead be "do you fall asleep?".  Of course I feel tired, I feel tired always!

Even non-(sleep)-specialists, like my psychiatrist, look at me, age and BMI both in the low 20s and say, nah, you couldn't have apnea.  It's just insomnia... but what stress is there in my life?  What little there is from sleep problems anyway!  And my insomnia does not fit the profile. I do not stay up late at night, obsessed with some problem, thoughts running through my head.  No, my thoughts start to quiet, and then snap, I'm awake again!  After a few repetitions I admit I get worried about being able to sleep at all, but that's really not the same.

Anyway, so far the results are very mixed with CPAP.  I do seem to be thinking clearer (especially first half of the day), and got to work earlier than I have in a long time.  But I still didn't feel great waking up and I wound up ripping the mask off around 5 (got up at 7:30) because the bloating from swallowing air was so bad.  I thought I was going to throw up when I woke up that time.  I really hope this resolves... CPAP holds such huge promise for my life.  I'm going to try messing with C-Flex and elevating the head of my bed, too.  I still feel kind of bloated and bleh, even now!

jrgoo27 wrote:

IainB - why is snoring a part of your definition of UARS?  I ask because I'm not a snorer - but I have many hypops and related arousals and no desats and am a poster child for the uars type symptoms.  My sleep doc diagnosed me with obstructive sleep apnea, but the uars descriptions fit me more - but i don't snore.

i've had an APAP for a few months and I can only sleep 1 to 4 hours a night on with it - with sleep meds.  that is a major challenge for people with sleep-maintenance insomnia.  my sleep doc said once i started the APAP, i wouldn't be such a light sleeper anymore but alas, it's not the case.

i hope you have better luck sleeplessj and thanks for those links.  jenny

Jenny snoring is one indicator and I may use it when I am scoring a sleep study or I may not. When I score I try to get a feel for what is happening in the patient. Scoring of sleep studies remains an art and while there is science we have not gottent to the point where analysis is pure science, despite the intervention of healthcare insurance companies. The desaturation definition is a MUST on Medicare and Medicaide patients. And yes I have seen patients with severe OSA who do not snore, and this can often be seen in patients who have had an UPPPS done.
Insomnia in patients who have a sleep related breathing disorder ( a much prefered description than OSA or apnea) is a complex issue and treatment can be difficult, my advise is to stay with it and let the CPAP device become your friend. AutoPAP can be benificial in that you are not at the higher pressures that you will only need during REM sleep and therefore this device will be easier to sleep with than a Regular CPAP device.
And as a last note, If your doctor is not listening to you then go and see another. Most and I repeat MOST, because there always will be exceptions, Sleep Docs will see you without a referral from a Family Doc.

Good luck with your CPAP therapy.

Iain


_________________
Iain Boyle MS, MLT(CSMLS), RPSGT

I don't know if UARS sounds more like me or not. Let's look at this paragraph from SleeplessJ's "UARS is a distinct syndrome" article....

"These patients frequently complain of insomnia, sleep fragmentation, and fatigue (5, 6). Their mean age is 38 ± 14 yr; 56% are women, and 32% are of east Asian origin. Hence, their sex, age, and racial distribution are different from those with OSAS. The mean body mass index is =< 23.2 ± 2.8 kg/m2, the mean respiratory disturbance index is 1.5, and oxygen saturation is >=  95%. Their craniofacial anatomy reveals a predominantly high and narrow hard palate, an abnormally small intermolar distance, an abnormal overjet >=  3 mm, and a thin soft palatal mucosa with a short uvula. In 88% of the subjects, there is a history of early extraction or absence of wisdom teeth (7). Their psychological profile shows a high anxiety score. Other clinical features are cold extremities, postural hypotension, history of fainting, and low blood pressure. In a subgroup of 15 subjects, between 20 and 30 yr of age, orthostasis is present by tilt testing, and is associated with a low mean systemic arterial blood pressure. Four breathing patterns are noted with repetitive transient arousals (8): (1) "Pes crescendo": progressively increasing esophageal pressure (Pes), terminated by reversal of the Pes to baseline; (2) increased Pes, without crescendo, terminated by a Pes reversal; (3) one or two breath increases in Pes preceding a Pes reversal; and (4) tachypnea with normal Pes, abruptly terminated by a normal breath. At the beginning of the sleep study, the average peak inspiratory effort during NREM sleep is low (mean Pes, -2.5 cm H2O). Typically, the events are terminated at low negative peak inspiratory pressure (-6 cm H2O) (9)."

No insomnia, sleep fragmentation. I don't think I'm fatigued when I sleep enough, but if I would go to bed earlier maybe I'd know. I've always been a night person; too bad I have to get up and go to work anyway. I'm in the age range, female, not Asian. BMI higher than their range, RDI higher, oxygen saturation lower. I don't know about the anatomy of my mouth, but it is difficult to floss between my molars and I had my wisdom teeth taken out when I was in my mid-twenties. Is that early? I definitely have cold extremities. Never fainted. Blood pressure is not low. The rest of the paragraph I do not understand.

Anyway, interesting, but I guess the upshot is, either way, CPAP. Right? I was titrated last night -- worse than the previous sleep study. My face still hurts 24 hours later from that stupid mask. I have no idea how I managed to sleep with it on eventually. I did bring earplugs, skimpier pajamas, and when I got hot I took off the top cover; still hot but better.

My face really hurts. I think it was a Ultra Mirage Mask from resmed; I don't know, but from looking at that on websites today I don't think they put it on right because I think the top T-bar thing is supposed to connect with your head somehow to prevent the thing from pressing into your face. The tech was condescending in a motherly way and not fantastic with English, and I tried getting her to adjust it and she messed with the straps, but it didn't make a big difference. But I saw a paper in the packet that they make you sign where one of the things they fill out on you is to rate your cooperativeness, and I'd already been uncooperative by asking her to not hook up the leg thingies since the last study showed no PLM's (no dice!), and I was feeling hopeless anyway about the existence of a more comfortable mask that wasn't exactly like the one my partner has, and what are the chances that they have that? (Nasal-Aire II, good times.) But anyway, if I had it to do over I would ask for something else. Because, ow. Now I worry that she'll put down that that kind of mask is fine for me and the insurance company will refuse to pay for a more expensive kind, and no way would I ever, EVER get that kind of mask.

Ha! Psychological profile is anxious: check!

At risk of being branded uncooperative, when I get the results of this one I'm going to ask for better data on both. And I want one of those data-giving CPAP machines too, so I can see if it's doing anything. I get the sense from the manuals that it might be a challenge to get info out of the machines, though? Their tone seems to be "don't worry your pretty little head about the data, let the nice DME handle that. COMPLY! COMPLY!" Everybody in this industry seems out to treat patients like children. Secret codes on the machines, manuals that don't detail how to use all the features, that intimidating "cooperation" scale at the sleep lab. You know, when they give you drugs they trust you to take the right amount. I technically COULD squirt my whole bottle of flonase into my head at once, but you know what, I take it as prescribed even if my nose is still itchy after two squirts, because I'm not an idiot or a five year old.

Gah.

UPDATE:

Well this is interesting. I just got the report from the titration study. Although they were able to get hypopneas down to only 2 events in 121 minutes with 7 centimeters of pressure, my minimum oxygen saturation for that period was still an 89! Mean is 93.6 for that period.

With pressure at 3 cm, I seem to have better results in the o2 saturation column, but still lots of hypopneas. Also, my minimum saturation in the non-titration study was 87, which is better than my minimum saturation in this titration study.

This is all very weird. Given that the positive airway pressure doesn't appear to be affecting my oxygen saturation, would you still get a CPAP? Is there some other option, like maybe breathing exercises or something, that you have heard of? I like oxygen!



I have sent a fax to the sleep lab asking for more detailed reports with graphs and position info and whatnot, so we'll see if I get those.

Also, sorry for the whining in the last post.

ANOTHER UPDATE

I got a message from my doctor. He said although the numbers look bad it's not as bad as it looks because the oxygen just dipped under 90% for a few seconds here and there. I guess they got better reports than I did, despite my request to the lab.[/b]