I finally got the results of my study. Haven't heard from a doc yet, just demanded to see the results.

Diagnosis:
1. Severe obstructive sleep apnea syndrome with hypersomnolence with mild oxygen desaturations.
2. Insomnia

*Is it rare to have both?

Sleep efficiency 62%
sleep onset time 29 min. REM sleep latency 265 minutes, which was prolonged.

Overall RDI was 34 per hour
Overall AHI during sleep was 1 per hour

*Okay, and this freaked me out:

"Prolonged cardiac rhythm monitoring was remarkable for the presence of PVC's."

*Is this something that will be resolved with CPAP?

Total sleep time: 272 min (4.5 hrs) (shocking to me that I sleep that much)
Awakenings: 53, Index 11.7

TST-REM: 68 min (1.1 hrs) Sleep Efficiency 62.5%

*What does the Sleep Efficiency number mean exactly?

Wake after sleep onset: 134 min (2.2 hours)

Latency to stage 1: 20, 2: 64, 3: 86, 4: N/A, REM: 265 minutes

N/A on stage 4 - what does that mean??

Longest event: 33.1/REM, 31.6 Non-REM, 32.9/Non-Supine, 33.1/Supine

Obstructive apneas:  looks like 2 total - 1 in stage 2 and one in stage 4

RERA's ??? Total sleep 149, REM 11, Non Rem 138, Supine 80, Non Supine 69

THANKS! Glad I finally know what I'm dealing with.

Jenny

If a latency to a sleep stage is N/A, it means you didn't have any.  But if there was an apnea in stage 4, then it means you did, so I don't get that.

PVCs are generally harmless unless if have a lot of them.  Or if they come from different sources.  Or if they double or triple up.  Or more.  Or if they alternate with normal beats.  Stuff like that.  They probably won't change with CPAP.

Sleep efficiency is the time spent asleep as a % of test time (lights out to lights on).

Yeah, that overall sleep architecture is pretty stinky.  But to base a diagnosis of insomnia on a single night, especially in a sleep lab, is not appropriate.  Hopefully the rest of your history was taken into consideration.

There's apneas, hypopneas and RERAs.  A RERA is a respiratory effort related arousal.  An arousal that is caused by a respiratory event other than an apnea or a hypopnea, like a snore or a flow limitation.  The RDI, then, is apneas, hypopneas and RERAs.  AHI is just apneas and hypopneas.

The severity of OSA is based on AHI.  If your AHI is 1.0, you don't have severe OSA.  You don't have OSA at all.  Now, you can have a bad case of Upper Airway Resistance Syndrome, but that's different.  Still could probably respond very well to CPAP, however.
sleepydave

They said "Laboratory severity rating is based on RDI, as per AASM consensus where: Mild=5-15, Moderate 15-30, Severe >30."

I thought 1 sounded "off" for severe.

So if the diagnoses are off, makes me doubt the results now.

Would there be a more appropriate treatment if it's not OSA? I'll have to do some research on Upper Airway Resistance Syndrome.
I've had bronchitis several times, and pneumonia once (that might have really been bronchitis, not sure) Could that be related?

It also said CPAP was not started because the patient's sleep efficiency was not high enough in the first 2 hours of the night.
Is that typical?

Thanks sleepydave! I'd be lost without your explanations!

Hi Jenny33:
Well, here's the hot off the press AASM Practice Parameters:

Practice Parameters

And as you can see, it's the AHI that's used in all the measures of severity in OSA.  RERAs needed objective criteria, such as esophageal pressure measurements, to be classified as an event, and I don't think they did that.

Now that said, you still have 149 respiratory arousals to deal with, and it's those arousals that make you sleepy during the day.  And CPAP will still probably be an excellent way to get rid of them.  However, if the arousals are due to something like primary snoring, then a lot of other options like surgery, implants, dental devices and the like may also be very effective.  True obstructive apnea is generally much less responsive to those approaches.  Just get another PSG afterwards to make sure they work.

Don't see where pneumonia or bronchitis will have a bearing.
sleepydave

Yo Jenny33:
Let's get back to that insomnia thing again.  Did the night in the sleep lab represent a normal night, or was that entirely different?

With that bad a night, there could be something else underfoot. too.  Any medications or other significant medical issues?

Find out what their scoring criteria for RERAs are, and if the respiratory events can't be associated with flow limitations, or at least snoring, or if things don't change with the application of CPAP, then it's probably not even UARS.

Maybe it's the cynical me, but some folks toss that RERA thing out far too liberally, and there's still unanswered stuff here.  I'd keep a real open mind until all your issues are resolved.
sleepydave

sleepydave,

Thanks for that info on AHI/RDI.

Not sure what you mean by normal night. I was there for a full night - from 9 pm to 5 am.
 
I'm not sure where the insomnia diagnosis came from other than they may have taken that from
my questionaire. I do sometimes have trouble getting to sleep. Some nights are worse
than others.

My only medications are for allergies - and I don't take them all the time.
I take Claritin as needed. Flonase - I was just given a sample from my PCP after
the initial consult. He told me I have narrow nasal passages. And I had been more congested than usual.
I decided I didn't like the way my nose felt after taking, so haven't
taken it much. But I think I used it that day of the study.

No significant medical issues. Other than my BP has been high for me - 130/90, when
it's usually 120/70 ish.
My blood work was all normal, including thyroid and cholesterol checks.

I did however have a bout of Asthma-type symptoms a while back, so I'm wondering if there are
lingering effects. I was on all the Asthma medications
for a while (Advair, Albuterol, Singulair) until I discovered the trigger. And I have been
off all of those meds for probably a year.
My PCP at the time never diagnosed it as Asthma - he used "Reactive Airway Disease" (or something like that)
When I am very stressed out, sometimes I feel it in my chest. Feels like the bronchitis days.
But generally I feel fine other than mild seasonal allergies.

But I was also wondering if maybe it could be acid reflux? Occasionally I have bad
nights where my chest hurts.
Not sure what the cause of that is.

I will ask further about the RERA's. On the graph, there are a ton of those (149), and only 2 OSA's, 4 hypopneas.
One of the things the reports says is as follows. Don't think I posted this:

"Trachal microphone monitoring revealed no frequent snoring."
Not sure what that means exactly... but looks like I only had 2 snores
It's pretty hard to read the graphs because it was faxed, but there are two snore lines
One is a straight line. The other has two little "blips."

Other things I didn't post:
There's a note at the bottom of one page: "unifocal PVCs"

There's also a really small graph at the bottom that confuses me. It has a line that looks like it says CPAP ??? I didn't
have CPAP. These are the other items in that tiny graph:

Hypnogram
Body Position
(CPAP?)
Respiratory (Module?)
SaO2
Arousal Module

Another question for them - could it be that these aren't even my results?!

I'm definitely keeping an open mind. I guess I'll see what happens with CPAP/titration.

I feel well informed. I read up on this Forum before going to my PCP and
I think because I was clear on the symptoms he gave me no trouble ordering the
sleep study. I think if I wasn't so prepared, I'd probably be on sleeping pills for
isomnia about now

Really appreciate the input!!!!

Just realized I read the OA's wrong. I thought I had one in stage 2 and one in 4.
I read the columns wrong..


I actually only had one total. Which was in non-REM and Non-supine.

I still need to get to the bottom of all those RERA's.

Only 1 OA?  Omigod!!  That changes everything!!

Just kidding!!

Only 2 snores all night?  That kinda limits the snore arousal angle, don't it?

Anyway, here's an example of flow limitations, which is a way you can objectively score RERAs.  Once again, we need to call on the lovely and gracious restedgal for loaning us her FLs:



Now, this is a 5 minute block of PSG, and we want to look at the breathing flow channel, labelled PTAF/CPAP.  The center of the waveform represents relatively normal breathing, kind of a sharp up and down movement.  But then the tops of the waveforms get flattened out at the top as some airway restriction occurs.  This continues until there's an arousal, and you can see this as a blip in the snore channel and the EEG gets a little dense ("the arousal").  You can see that there's 2 of these in this example.

Hopefully they're using some kind of objective criteria to rate the RERA.  If they're not, then you have to wonder about another source of the arousals other than airway involvement, but maybe that's getting ahead of the story.  Suffice for now that this needs a critical look and explanation.
sleepydave

sleepydave,

Unfortunately, squint as I may, I can not make out some of the labels on the graph. I see a line that looks like
it says CPAP - but I don't see PTAF/CPAP.

I don't even understand why the CPAP line is active up/down when I did not have CPAP. Or is it just a
generic label?

There are little boxes with the word RERA. And right after those RERA's, all the lines at the top get really dense. But I can't make out what those lines are. Frustrating.

I assume this is a situation where I need to get an appt with the sleep doctor for further explanation--
Should I do this first before I go back for CPAP?
Or should I see if it is resolved by CPAP first, and if not, deal with it then?

Thanks restedgal for the loaners!

sleepydave, thanks so much for looking at all of this. And for explaining things so well in layman's terms.
I'm depressed at the thought of waiting who knows
how long to get this straightened out. I am just absolutely exhausted.
But it does help to have a sanity check.

Happy New Years!!

Yo Jenny33:
No, your graphs are someting different, they represent the whole night, so they're more like a summary of things.  The thing above represents an actual PSG, which no one ever normally sees.  This is the thing that the scoring is done from to create those graphs and summaries.

You could go either way.  If you go the CPAP route, and all the RERAs disappear, and you feel better, then happily ever after.  If the arousals remain and there's no change, there's more work to be done.  I don't think it's an unfair question to ask, are the RERAs based on something like flow limitation, and for a minimum time, like 10 seconds.  But some folks will just blindly call all arousals RERAs without cause (hey, that reminds me, do you have the summary of ALL arousals?  Were there some spontaneous as well?)  And this bit about one OA and a bunch of RERA, and surprise you've got severe OSA is a stretch.  The criteria that they quote from the AASM standard is from 1999, where they also said that RERA needed to be identified by esophageal balloon and be 10 seconds long.  Still do in the new standard.  But again, RERA is an "RDI" event, and most people use "AHI" in determining disease severity.  Yes, I know it's confusing, has been for years, but I think you can see now that knowing the difference here can make a big difference in not only the understanding of what you have but the treatment as well.

Ooh, that reminds me of another thing.  Many insurers (like Medicare, for instance)(yeah, I know that's not you)(or maybe it is, you're just starting your family late?)(but a lot of insurers use Medicare criteria) anyway, they use the AHI as their criteria to allow the CPAP titration and the purchase of the machine.  The minimum AHI in those cases is 5.0 at the least, sometimes more.  So that 1.0 might give you another issue, better check that out beforehand.  If your insurer doesn't think you have "severe OSA" either, you're gonna be out about 4G's.

Isn't this interesting?
sleepydave

sleepydave,

Thanks. You've given me a lot to think about.

As far as the summary of all arousals, I don't see anything specifically referencing spontaneous arousals.
But they reference arousals and awakenings - not sure what the distinction is there.

Time in bed                     435 min <7.3 hours>     Total arousals 28                          Index (6.2?)
Total Sleep Time (TST)     272       <4.5 hours>      Awakenings 53                             Index 11.7
TST-NREM                       206       <3.4 hours>      (Arousals + Awakenings) (81)        Index (7.8?)
TST-REM                         68         <1.1 hours>      Sleep Efficiency 62.5%
Sleep Latency                  29            <.5 hour>    
Wake after sleep onset    134         <2.2 hours>
(Latency Persistent sleep?) (61)      <1.0 hours>        

The ones in parentheses were hard to make out because of the shading.

PLMs - all 0's.

Re: insurance - nope, Medicare is not me yet I'm 37.  I have MDIPA/MAMSI insurance.
I have 3 kids - 10 yo son, 7 yo twin girls. I was told by my day care provider that the twins
snored incredibly loudly when they were toddlers. (And one freaked them out one day screaming with
night terrors) Soooo, I'm keeping a closer eye on them now. (The one w/ night terrors was
not the one I posted about in the pediatric forum.) It's never a dull moment!

Thanks for the heads up. I would not be a happy camper if they refuse to
pay for the CPAP titration, especially since that was the primary recommendation.
Sounds like this lab has issues.

This is all VERY interesting.

Quote:

This is all VERY interesting.

Well hang on to your seat cause it's about to get a heckuva lot MORE interesting.

The thing that makes a RERA a Respiratory Effort Related Arousal is, well, the arousal.  So if you only have 28 total arousals, the most RERAs you could have would be 28.  Even if you were to count in the awakenings, which typically are not RERA-type events, as you see that only gives you 81, for an index of 17.8 (there should be a "1" in front of that 7.8).

My gut feeling right now is that with that many awakenings, and that poor sleep efficiency, and an extremely questionable respiratory ANYTHING, having a CPAP titration would result in you staring at the ceiling all night.

If your daily sleep quality is similar to the night in the sleep lab, then insomnia is the main culprit here.

I would really challenge them to show you how they came up with "severe OSA" and the chance of CPAP success based on these points.
sleepydave

sleepydave wrote:

Hi Jenny33:
Well, here's the hot off the press AASM Practice Parameters:

Practice Parameters

sleepydave

Thanks for this link. It has lots of great information, including when a follow-up psg should be done.

and I am desperately holding onto my seat!

Guess I need to start reading more about Insomnia. That part of the diagnosis was "Insomnia NOS"
(I assume NOS is "Not Otherwise Specified.")
And the only recommendation was "behavioral and pharmacologic treatments for insomnia may be helpful."

Not sure which emoticon is more me right now:

  or  

Fun Stuff to Know and Tell About Insomnia
s.d.