Hello SleepyDave,

Well I’ve learned more from your post about how their internal criteria might have been working at cross purposes to the doctor’s prescription.  Until you mentioned that the prescription should have been more specific I didn’t think this could be an issue.  I felt that way because I’m not sure the form that the clinic provided can accommodate being more specific than it is without it providing a comment section, which it doesn’t.  Their form shows a list of 11-procedures they support.  Some are combinations of the other items on the list and some have subcategories that can be selected to tune the process.  In my case, we already had a sleep study from 7-years ago that indicated an obstructive condition, so this was to be a follow-up study to determine what CPAP process would allow me to sleep on my back.  I tried in many different ways to communicate that to the setup technician who also uses CPAP personally.  This is why I felt so blind-sided by the outcome.

As for time on my back, the only recording they have with me on my back will clearly show I was awake trying to sleep.  At least I hope the recordings can tell if I’m awake or asleep.  Is the equipment that sensitive?

There shouldn’t be too many obstructive events recorded, if any, because when I was on my back I was awake.  When I’m on my back and an obstructive event occurs, I stop relaxing for a while keeping the obstruction cleared.  This routine would happen each time I woke up and tried to sleep on my back.  As for events on my side, over the last 15-years I’ve honed a process of dealing with my obstructions by sleeping on my side with my face rolled down off the pillows.  For the last two-months I’ve tried to get past this behavior so it wouldn’t blind the testing, but when I would awake, there I was in that same coping position.  The setup technician was told of this and was asked to ask me to roll on my back.  Not once did they ask or tell me anything during the sleep study.  However, one of the technicians would talk to me when I would call to get untangled for a restroom break.  If I had know what time these breaks were happening, I could have asked for the second phase, but being so tired I never asked about the time until the last break at 5:30AM.

I’m going to let this thread sleep until the paperwork arrives and then I’ll report what I learn.  I’m sure hoping I’m missing the obvious here, but if I am, I’m not smart enough to know what it is right now.

Thanks again for responding.  Hearing a lab’s perspective is certainly taking some of the anger out of the disappointment.  Maybe this will all work out to be a big misunderstanding.  Then the question is who pays for the repair and which procedures will be billed.



Last edited by Roger... on Sat Oct 01, 2005 5:35 pm; edited 1 time in total
_________________
Thanks,
Roger...

Hi Roger:
Yes, I think that's the best approach.
It'll be easy enough to figure out if there was a major foul-up.
sleepydave

A few minutes ago I called to get a status because we are on day-8.  When the person in charge got on the phone he mentioned it could be a month or more before the report is finalized.  This was a surprise so I mentioned the conversation I had with the person making the appointment that the timing would be about a week to 10-days.  With that expectation passed along  I asked him "Why does it take so long?"   "We have a doctor in Los Angelas who reads the reports only at night.  He has a regular practice during the day, but does our reports at night when he gets home.  Right now I've got a group of 12-report to fax to him today and will be sure your results are included in the batch I fax out.  From there it takes 2 to 3 hours to read a report and comment, so we could get an answer back tomorrow, but maybe not."

I didn't know whether to laugh or cry when I heard their arrangement.  Clearly, if a medical review is needed, I would think something might be handled during hours when people weren't tired, or busy passing the salad and beans, but I guess getting a good review isn't as important as adding a billing line item.

I think this Sleep Testing business could use some growth in structure so things don't happen by chance quite so often.


_________________
Thanks,
Roger...

Roger,

I must say that I have to agree with you.  I found that for both of my sleep studies, 3 weeks or so passed until I received a copy of my results (after making a pest of myself).  After receiving a 2nd opinion on the type of machine I needed (as well as the correct pressure), I'm still waiting for my insurance company to hopefully approve and pre-certify me for autopap (again calling and making a pest of myself nearly daily).  The insurance company (Blue Cross) has had it in their hands for 1 week as of today.   I find it rather sad that there is so much waiting even though it's my cardiologist who is insistant that I get CPAP therapy.  Each time I call him with blood pressure problems they throw a fit when they find out that I'm still not getting the CPAP therapy since he feels it might have been sleep apnea and low oxygen levels that caused my ventricular tachycardia heart rhythm back in June not to mention the elevation of my blood pressure.  

   Lots of days of this!

Good luck to you and I hope things start moving a little faster for you, me and all who need our theraputic Xpap's.

Linda (roseinpa57)

I am using a bi-pap machine for my apnea.  My questions are, where do I purchase the software to read the results of the card, can the results remain on the card for my pulmonologist, and is it difficult to read the results?  When I went to my pulmonologist yesterday, they downloaded the info from my card.  I asked him to explain what it said and he did a quick little explanation that I was using the machine on average 6.5 hours a night.  He didn't tell me anything about the numbers of apneas or hypopneas I was experiencing with the machine.  Do all machines provide this information?

Thanks for your help!

Cheryl

Another call to the sleep center had the report on my fax machine within minutes after they apologized for not remembering to send it.  In hearing their reasons for being forgetful, I’ve come to the conclusion this location is showing severe signs of being over worked and understaffed, or maybe something worse we won’t ponder.  

When the report arrived there were some simple errors and a misstatement.  Pointing out these issues quickly found agreement and produced a corrected report a short time later.  Seeing this process in the daylight helped me understand more as to why I found the experience less than polished, but it didn’t change my uncertainty with the outcome and results.

These report details are verbatim, except for the removal of the doctors involved and the description of the patient.  What they wrote about me in way too many lines is basically what I’ve listed, and my version is certainly easier to understand.

With this story reasonably well documented, it appears hardware is warranted, but I still don’t understand why they didn’t do the split study even with what they listed.  

Quote:

OVERNIGHT POLYSOMNOGRAPHY REPORT
 
PATIENT: ROGER...
 
DATE OF STUDY: 9/1412005
 
INDICATIONS:
This is a tired old man that makes noise when asleep and is becoming more than grumpy.
 
PROCEDURE:
An all night comprehensive sleep study was performed in which the following medical parameters were recorded using a Healthdyne model Alice 3 computerized polygraph, left central (C3), central (CZ), occipital (OZ) and frontal (FZ) electroencephalogram, left and right electrooculogram, electrocardiogram, submental & anterior tibialis electromyogram, nasal/oral airflow, oxygen saturation (pulse oximetry), chest & abdominal effort belts, sonogram (snoring) and body position monitor. The study was attended by polysomnographic technologist (PSGT) and the raw data was manually reviewed and interpreted by xxxxxxxxxxxxx, M.D., Diplomate of the American Board of Sleep Medicine. The recording started at 9/15/2005 at 10:42:55 PM, 9/15/2005 at 5:31:55 AM.
 
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.
  
• Respiratory related sleep fragmentation: Sleep arousals due to respiratory events or snoring.
  
• Sa02 Scale: > 89% (none), 85-89% (mild), 80-84% (moderate), <80% (severe).
  

 
CONCLUSION:

• Moderate obstructive sleep apnea with an Apnea/Hypopnea Index (ABI) of 27.5 per hr.
  
• Severe Sleep related oxygen desaturations.
  
• Sa02 Nadir of 78 percent from a sleep baseline of 92%.
  
• Severe respiratory related sleep fragmentation with a Respiratory Arousal Index (RAI) of 39.48 per hr.
  
• Moderate to loud snoring was noted.
  
• ECG/EKG abnormalities were not noted.
  
• EEG or EMG abnormalities were not noted.
  
• Average duration of hypopneas was 21.2 seconds.
  
• Maximum duration of hypopneas was 37.0 seconds.
  
• Average duration of apneas was 17.0 seconds.
  
• Maximum duration of apneas was 21.5 seconds.
  
• CPAP was not applied due to lack or sleep efficiency. Sleep efficiency of only 60.6% did not allow enough time to properly make an evaluation. A longer diagnostic was needed to better access the patient's severity.
  
• 
  

 
DISCUSSION:

• Once asleep, the patient demonstrated moderate-loud snoring and repetitive obstructive apneas and hypopneas with an overall apnea/hypopnea index of 28 per hour, placing the patient in the moderate category. Obstructive events were associated with severe oxygen desaturation to as low as 78%.
  
• There were no EKG abnormalities.
  
• There were no REG abnormalities.
  
• There were no periodic limb movements.
  

 
Options for treatment of this patient's obstructive apnea include the following:

1. Discuss the importance of weight loss, if Indicated
   
2. Discuss the role of alcohol and sedative/bypnoties in causlng or worsening existing obstructive apnea
   
3. CPAP/BlPAP
   
4. Dental appliances
   
5. Surgery
   

 
Recommendations should be made based on a thorough evaluation of the patient. Clinical correlation is suggested.
 
SLEEP ARCHITECTURE BASELINE PORTION OF THE STUDY:

Code:

TOTAL SLEEP TIME:       231.0 min.
TOTAL TIME IN BBD:      381.0 min.
TOTAL WAKE TIME:        0.00 min.
SLEEP EFFICIENCY:       60.6%
LATENCY TO SLEEP ONSET: 11.5 min.
LATENCY TO REM ONSET:   363.0 min.

 
SLEEP STAGES:

Code:

                     Minutes     %TST
Stage I:             46.0        19.9
Stage 2:             167.0       72.3
Stage 3:             13.0        5.6
Stage 4:             0.0         0.0
REM Sleep:           5.0         2.2
 

 
AROUSALS:

Code:

                                 NUMBER      # PER HOUR
EEG AROUSALS (TOTAL):            180.00      46.75 per hr.
RESPIRATORY & SNORING AROUSALS:  152.00      39.48 per hr.
PLMS AROUSALS:                   0.00        0.00 per hr.
NON-SPECIFIC AROUSALS:           28.00       7.27 per hr.

 
RESPIRATORY EVENTS:

Code:

                                  # PER HOUR:
Apneas:                             6
Hypopneas:                          100
Total apneas/hypopneas:             106
Apnea/hypopnea Index:               27.5
Snoring related EEG arousals:       11.95
Respiratory Arousal Index:          39.48
 
Body Position Table           Supine         Left        Right       Prone
TST in min.                   9.93           45.51       175.42      0.10
Sleep %                       10.64          74.00       86.20       20.00
REM %                         0.00           0.00        2.50        20.00
CA                            0.00           0           0           0.00
OA                            0.00           0           6           0.00
MA                            0.00           0           0           0.00
Hypopneas                     3.00           19          78          0.00
AI (#/Hr)                     0.00           0.00        2.05        0.00
AHI (#/Hr)                    18.13          25.05       28.73       0.00
RAI (#lHr)                    24.18          46.14       38.65       0.00
Snore Arousals                1              16          29
SaO2 Nadir                    89%            89%         78%

 
SLEEP STAGES:

Code:

               TST:        AHI:           Average     Min
                                          SaO2:       SaO2:
REM:           5.0 min.    72.0 per hr.   90%         78%
NREM:          226.0 min.  26.5 per hr.   92%         86%

 
DURATION OF APNEA/HYPONEA:

Code:

                              APNEA          HYPONEA
Average duration:             17.0 seconds   21.2 seconds
Maximum duration:             21.5 seconds   37.0 seconds

 
OXYMETRY SUMMARY:

Code:

Desaturation Index (number per hour):                 13.8
Baseline 02 saturation (Awake):                       93
Baseline 02 saturation (NREM):                        92
Baseline 02 saturation (REM):                         90
Minimum oxygen saturation with a respiratory event:   78
 
Oximetry Table    WK       REM      NREM        Total
<75 (min)         0.01     0.0      0.0         0.0
<80 (min)         0.0      0.0      0.0         0.0
<85 (min)         0.5      0.5      0.5         1.5
<90 (min)         2.5      1.5      14.5        19.0
 

CARDIAC EVENTS: Average heart rate waking: 86.4, NREM: 75.5, and REM: 71.0.

All Comments are appreciated


_________________
Thanks,
Roger...

Hi Roger!
Well, there's just about no supine time as you previously noted.  And I see that line where they mention that there wasn't enough quality sleep.  You had only 4 hours the whole night, so maybe so.

But you see this line?

Quote:

REM:           5.0 min.    72.0 per hr.   90%         78%

Your worst OSA, according to AHI and lowest desat, was while you were in REM sleep.  That's quite common.  As common as more severe OSA while on your back.  Anyway, that's kinda important information to know.  It would've been nice to get a lot more REM to better analyze that, too, but it just didn't happen.

But you see the problem?

Quote:

LATENCY TO REM ONSET:   363.0 min.

That REM period didn't occur until 6 hours into the study.  So it was nearly AM.

So yeah, they could make a fair case to gather info for the whole night.  Woulda been nice to get REM sleep while supine, too, you might've had REALLY had low sats.  And again, good info to have.

sleepydave

Hello Dave,

Thanks for checking back.  Your insights have been very helpful in understanding the sleep-testing process and also how to calibrate my observation against my expectations.

To add some additional insights to what happened and maybe why, I've attached a cleaned up graphic of the multi-graph image they faxed.  On this image the light grid lines are added so I could more easily understand what was happening when I was going from a sleep stage to being awake.  I also added some text to the Sleep Stage & Position sections so it wouldn't need a lot of scrolling to see what level the graph line was referencing.  Two of the left hand legends were smudged and were replaced with the information they gave me over the phone.

Quote:

there's just about no supine time

As for almost no Supine/Back time, I knew going in there wouldn't be much sleep on my back because of how difficult it is to breathe in that position once I begin to relax.  In the 15-years I've tried to ignore this problem, I did train myself to only sleep on my side so I have to really work at staying on my back now.  Because I knew that information would be helpful and because of my habit of side sleeping, I tried real hard to get the technician to help.  That approach didn't work, well I guess that's life.

Quote:

That REM period didn't occur until 6 hours into the study

It might seem strange to know the sleep was about average to what I experience at home, with the exception of how much I tried to sleep on my back.  If this test result is average indication, it indicates why I've not been dreaming much these last many years.

I think more importantly is the lack of S3 and no S4 sleep.  From what I've read, these are the stages I need to get my sense of humor and creativity back to where I need them.  Knowing this I can at least blame my grump behavior on something.  :)

Quote:

Woulda been nice to get REM sleep while supine, too, you might've had REALLY had low sats

I don't think I can sleep long enough on my back to get to the REM stage with my mouth closed and still be here to type.

Side Sleeping APNEA Confirmation
Going into this period where I've committed to changing my sleep conditions I suspected I was having obstructive events even when I was on my side breathing through my mouth.  This was confirmed by looking at the results on the graph.  When I would be on my side, I would start out breathing through my nose, but when I would awake I would always find my mouth open.  Clearly, side sleeping is only a band-aid on a gapping wound.  At some point you run out of energy and life becomes more work.

My Polysomnography Graph (Click Link below thumbnail  for a Larger Image)


Larger Polysomnography Report Graph

What Next?
In my last discussion with the Sleep Center, they mentioned I’d need to make another appointment so they can perform the Titration phase of the prescription.  

My mind is resisting this because of how things happened for this test.  My resistance comes a lot from how poorly they handled what I believed was our agreement to try to help me get on my back and to split the study as the prescription recommended.  They knew that this wasn't my first study, but the technician went to great lengths to convince me that I would need to come back two to three times before they would be able to get enough information.  That effort by the technician and the failures during the study left me with the feeling they were building sales by double-booking the people.  This might be way off base, but the feelings are still strong that this was what caused the failures.

Another aspect that is causing me to resist is the ability to get hardware that will give me enough information on how to calibrate the machine to fit my treatment needs.  If I can gain as much information about what needs to be done by just downloading each nights results and viewing them in the companion software, why spend money on another appointment when I could put it towards the expense of a machine setup?

If I could get a sleep center's perspective on how they might offer me an advantage it would help me get past the resistance.

Thanks again.


_________________
Thanks,
Roger...

Hi Roger!
Having the graphics certainly makes looking at the over-all sleep picture much easier.
You say this was read by a Board Certified Sleep Specialist?  What'd he say about your sleep architecture?
Boy, it's a wreck!  I can see why the tech was so reluctant to start any treatment, there's almost no continuous sleep till 4:30 AM, then it's way too late to start anything.
Hmm.....the next step.  You gotta fix that sleep maintenance insomnia issue, as you say that's a pretty average night.  There could be a bunch of causes, but you might start out with any medications you might be on, and reviewing all the basic sleep hygiene stuff.
I think I'd put the onus back on the sleep doc, and ask him how he intends to deal with that sleep architecture issue.  It will be just as important, if not more so, as the CPAP.
Write back.
sleepydave

sleepydave wrote:

Having the graphics certainly makes looking at the over-all sleep picture much easier.
You say this was read by a Board Certified Sleep Specialist?

Hello Dave,
It was great to hear your perspective.

Yes, the doctor shows he is a Diplomate of the American board of Sleep Medicine.  I’ve always taken these things to mean dues are current, and not much else.  Is this an effective organization?

sleepydave wrote:

What'd he say about your sleep architecture?

 Everything that has been said by everyone involved is posted here, including the sleep-doctor's comments (see the clinic’s report above).  My doctor has not been available in the couple of days since the report was sent, but he is a family practitioner, not a sleep specialist.

As for what the sleep-doctor wrote, the sleep clinic said the doctor that reviews the testing and makes recommendation does the analysis in the time between dinner and going to bed.  That situation is another area where my confidence in this clinic was reduced.  I had hoped a doctor was tied to clinic, but I didn’t check going in because the last sleep test clinic had one, so I assumed they all had sleep doctors.  This one is my fault for not checking.

With the clinic’s doctor doing the work as a night-shift analysis, I guess I shouldn't expected anything other than pathetic results.  Should I expect more?

sleepydave wrote:

Boy, it's a wreck!  I can see why the tech was so reluctant to start any treatment, there's almost no continuous sleep till 4:30 AM, then it's way too late to start anything.

If that is the reason they didn't follow through, then I can live with the current outcome.  However, when I’m told they are short-handed on my test night, and with a perceived propensity to have people come back, I'm not sure.  I'm not sure because I told the tech this would happen going in.  Hearing that you would have reacted the same takes the steam out of my perception, so I’ll give them the benefit of the doubt for now.  However, if you had been told what I state at the beginning of this thread, I don’t believe you would have been so absent and non-communicative during the testing.  Did I get that right?
  

sleepydave wrote:

Hmm.....the next step.  You gotta fix that sleep maintenance insomnia issue, as you say that's a pretty average night.  There could be a bunch of causes, but you might start out with any medications you might be on, and reviewing all the basic sleep hygiene stuff.
I think I'd put the onus back on the sleep doc, and ask him how he intends to deal with that sleep architecture issue.  It will be just as important, if not more so, as the CPAP.

Fixing the “insomnia issue�
If you take a look at the graphic, you'll see that I toss and turn all night from one side to the other.  On the test night I tried to get some back time, but none of the back time shows any sleep.  This tossing and turning comes from the problem I have with my arms going to sleep when I'm on my side.  In my case, I can sleep on my side until my arm begins to hurt.  When that happens I wake and roll to the other side.

During the time shown when I'm on my back, I kept gagging from the early obstruction blocks.  They don't show on the Hypo or Desat lines, but do show as peaks in the BPM section.  This problem was also passed on to the technician before the testing that night.  Why they didn't come in when I was gagging left me thinking they were not paying attention, or the new girl they had in training had no idea what was happening, or worse.

Medications
Accupril & Triamterene/HCTZ & St. Joseph's 81mg Aspirin taken in the early morning (~6:30AM) are my only meds.  My family doctor says they have no sleep impact.

�Food Drugs�
There isn't any caffeine, alcohol or soda pop in my diet.  Small meals (<500 Cals) at dinner, and never past 7:00PM with a glass of Fat Free milk.  That is it for foodstuffs.  

�Adrenalin Pump�
I stopped working after 6:00PM years ago so I wouldn't be caught up in work-worries.  I won't watch exciting or emotionally stirring shows because they wind me up.  I won't exercise after 8:00PM so that doesn't get the juices pumping.  From what I know and what the doctor indicates, there isn't anything else I can take out.

�Sleep Station�
My home mattress is a controlled cell air mattress adjusted to give me the best feel when sleeping on my side.  Since I bought this mattress, I’ve been sleeping so much better that I find it concerning to sleep elsewhere even though some of the high-end hotels do have real good mattresses.

As for falling asleep, I’m so tired all the time that I go out at the drop of hat when I'm on my side.  I think the graph shows this well.  Am I reading it wrong?

In reading just about everything I can find, I’m running out of solutions.  If CPAP doesn’t get me on my back and rested, then I’ll be scratching my head wondering what else, other than arm amputations, might be useful.

sleepydave wrote:

Write back.
sleepydave

I’m very grateful you’ve been so helpful in helping me calibrate and think about alternative perspectives.  I’m learning at a rapid rate, and have now become more hopeful I’ll find the pony that is causing all this !@#! to happen.


_________________
Thanks,
Roger...

I heard someone talk about sleep apnea recently and it rang a bell for me so I just looked this up (I'm new to e-mailing and such). I just quit smoking 4 weeks ago and since then have been waking up gasping for air several times a night and have hardly slept at all. During the past year I've had some tests done on my bladder because of some pain in that area and night frequency. - to no avail. I'm having ultrasound done in a month on my abdomen. Also I get extreme sweats, partly due to menopause, but more since I quit smoking- I can't make decisions, have no energy and am weepy. It almost feels like a relief to think there might be an answer here somewhere. I don't have a lot of faith in Dr.s. Sleepy Dave sounds like he has a lot of wisdom about this topic. Any help would be appreciated. Thanks monicaincomox. I hope I can find this again.