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Home Sleep study questions
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SleepyHoosier Offline

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Post: #1
Home Sleep study questions
New to this forum, and wanted to thank you all for all the useful information here! Little bit of a backstory first... I was diagnosed about 5 years ago with moderate sleep apnea after a sleep study in the lab. I've had a lot of difficulties over these 5 years with being compliant. I've tried dental appliances and multiple masks over the years and nothing has stuck. I'm mad at myself for giving up on it, but wanted to try again as I know the benefits of it. Anyhow, I talked to my family Dr. and he tried to set me up with another sleep study since it's been about 2 years since I've last tried.. My insurance denied the lab sleep study but did approve a home Sleep study. I just got back the results from the home study and it showed that I wouldn't even be considered for a cpap now. Nothing has really changed in regards to losing weight etc, so I'm just wondering how common is this? I guess I was under the impression that this would follow me the rest of my life. Are home studies usually accurate enough? The sleep doc wants to see me, but that appt isn't for another month. I'm not complaining that my home Sleep study came back good, just wondering if it's really accurate enough..

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05-16-2016 12:48 PM
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trish6hundred Offline

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Post: #2
RE: Home Sleep study questions
Hi SleepyHoosier,

WELCOME! to the forum.!

Hang in there for answers to your question about your home study.
Much success to you.

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05-16-2016 01:20 PM
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0rangebear Offline

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Post: #3
RE: Home Sleep study questions
Hi
Welcome
(05-16-2016 12:48 PM)SleepyHoosier Wrote:  New to this forum, and wanted to thank you all for all the useful information here!
Were are hear to help
I-love-Apnea-Board
(05-16-2016 12:48 PM)SleepyHoosier Wrote:  I just got back the results from the home study and it showed that I wouldn't even be considered for a cpap now.
Can you post the some data from sleepyhead? The folks on the forum typically need to see the Data to form their "Words of Wisdom" which will help you deal with your situation.
(05-16-2016 12:48 PM)SleepyHoosier Wrote:  Are home studies usually accurate enough?
Hospitals, labs and home sleep tests are all vulnerable to the same problem "People make Mistakes" Hard to know if that happened with specific Data from the test.

Did the sleep test monitor you O2?
Does the AHI correlate with the sleepyhead data from your machine?

These would be good things to clarify before you see you Doctor.

2004-Bon Jovi
it'll take more than a doctor to prescribe a remedy

Observations and recommendations communicated here are the perceptions of the writer and should not be misconstrued as medical advice.
05-16-2016 01:24 PM
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robysue Online
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Post: #4
RE: Home Sleep study questions
(05-16-2016 12:48 PM)SleepyHoosier Wrote:  New to this forum, and wanted to thank you all for all the useful information here! Little bit of a backstory first... I was diagnosed about 5 years ago with moderate sleep apnea after a sleep study in the lab. ...
I talked to my family Dr. and he tried to set me up with another sleep study since it's been about 2 years since I've last tried.. My insurance denied the lab sleep study but did approve a home Sleep study. I just got back the results from the home study and it showed that I wouldn't even be considered for a cpap now. Nothing has really changed in regards to losing weight etc, so I'm just wondering how common is this?
My guess is that the discrepancy is most likely due to how the hypopneas were scored on each of the two tests.

I apologize in advance for the fact that much of what follows is quite technical and might be difficult to follow.

Some insurance companies (particularly Medicare) and the sleep medicine community are arguing over what should count as a "hypopnea" on a sleep study. Medicare and some insurance companies insists that a hypopnea must have a corresponding 4% drop in O2 saturation to "count", but the data from multiple scientific studies indicates that "hypopneas with arousals" are just as disturbing to the sleep and can be just as damaging to the long term health of the person. Hence most sleep docs would prefer to use a definition of "hypopnea" that requires a 50% drop in airflow accompanied by either an EEG arousal OR a 3% drop in O2 saturation and many sleep labs routinely score "hypopneas with arousal" as hypopneas that count towards the diagnostic AHI.

For the past decade or so, the AASM has allowed sleep labs to score hypopneas with either criteria on in-lab test, but they are supposed to say something about which criteria are used in the summary data for the sleep study. For most people, the difference in computing the AHI using the two accepted definitions of "hypopnea" is negligible.

But if you are someone who's main problem is with "hypopneas with arousal", it is possible for the two hypopnea scoring schemes to lead to very different diagnosis. I am one such person: My diagnostic sleep test showed an AHI = 23.1 with a HI = 19.7 and an OAI = 3.9. And I was diagnosed with moderate obstructive sleep apnea and put on CPAP based on this sleep study. But all of my hypopneas were scored as "hypopneas with arousal" meaning that none of them "counted" in the Medicare AHI. Had my insurance company followed Medicare guidelines, I would not have qualified for CPAP because my Medicare AHI = 3.9, and with a (Medicare) AHI = 3.9, I would be diagnosed as "does not have OSA" under Medicare guidelines and definitions. (And I have confirmed that interpretation of my original sleep study results with two different sleep docs. A third sleep doc has looked at those results and told me more than once that I do not have OSA and that all my problems are related to borderline bipolarism, which my psychiatrist says I most definitely do not have.)

To complicate matters further: Some home sleep tests are better than others in terms of the data they actually gather. Some of them are pretty simplistic and amount to not much more than an overnight O2 saturation study with airflow data, where the major criteria used to score the events is a combination of drop in airflow with associated drop in O2. Others do have EEG leads or other ways to try to determine the sleep stage, and these studies can do a better job of picking up "hypopneas with arousal".


So to come back to your original question: How is it possible that the in-lab sleep test said you have moderate OSA and the new sleep test says you don't have OSA at all?

My best guess is that the vast majority of your events on the test from 5 years ago were scored as "hypopneas with arousal". And that the home sleep test you took is either not set up to gather EEG data (and hence can't score "hypopneas with arousal" OR the company that scores the data uses Medicare's definition of "hypopnea" for scoring. And if you don't desat with the hypopneas, they don't count towards the home sleep tests AHI computation.

The only way to verify my hypothesis would be to look at the data from the original sleep test. Do you still have the full results of that sleep study from 5 years ago? And if you do have that sleep test report, do you know if you had a high Hypopnea Index with a low Obstructive Apnea Index? And if so, do you know if most of your hypopneas were associated with O2 desats of 4% or more?


Quote:I guess I was under the impression that this would follow me the rest of my life.
Ordinarily OSA is not just going to go away on its own. Particularly if there's been no change in weight or lifestyle.

Quote:Are home studies usually accurate enough?
Maybe. Maybe not. It all depends on whether the home sleep study was set up to detect "hypopneas with arousal".

Quote:The sleep doc wants to see me, but that appt isn't for another month. I'm not complaining that my home Sleep study came back good, just wondering if it's really accurate enough..
Is this the sleep doc who did the sleep test five years ago?

If not, it would be very useful if you can arrange for the original sleep tests results and summary data to be forwarded to him before your appointment.

If he's the one who was treating you five years ago, it's worth asking his staff to be sure to dig out the old sleep study report so that you and the doc can go over both reports.

It's also possible that some of the hypopneas on the original sleep study were very marginal events and that today they might be scored as respiratory effort related arousals. RERAs are not technically part of the AHI. But they can be disruptive to people's sleep. And there's a relatively new diagnosis call UARS (upper airway resitance syndrome) that is also somewhat controversial. Patients with UARS typically have low AHIs---as in AHIs that are well below the usual 5.0 needed to diagnose mild OSA. But patients with UARS also present with many of the same OSA symptoms: Lots of daytime exhaustion, brain fog, sometimes an awareness that the sleep is bad. They often don't have any snoring and bed partners may or may not say anything about witnessing problems with the night time breathing.

Treatment of UARS is usually with CPAP. Some insurance companies will routinely cover it. Others will question whether CPAP is necessary.

Good luck in finding some answers.

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05-16-2016 04:43 PM
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richb Offline

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Post: #5
RE: Home Sleep study questions
As robysue says: Show us some Sleepyhead data. We would love to help.

Rich
05-16-2016 05:17 PM
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robysue Online
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Post: #6
RE: Home Sleep study questions
(05-16-2016 05:17 PM)richb Wrote:  As robysue says: Show us some Sleepyhead data. We would love to help.

Rich

Rich,

It's not clear that SleepyHoosier is using his machine since his backstory is:
SleepyHoosier Wrote:I was diagnosed about 5 years ago with moderate sleep apnea after a sleep study in the lab. I've had a lot of difficulties over these 5 years with being compliant. I've tried dental appliances and multiple masks over the years and nothing has stuck. I'm mad at myself for giving up on it, but wanted to try again as I know the benefits of it. Anyhow, I talked to my family Dr. and he tried to set me up with another sleep study since it's been about 2 years since I've last tried..
My guess is that SleepyHoosier is not using his machine. A good question for SleepyHoosier is: Are you willing to dig the machine out of the closet and give it another go even though the home sleep study says "no apnea"?

SleepyHoosier's real question concerns the validity of the home sleep test that showed he does not have OSA when an in-lab test five years ago said he did have moderate OSA.

And all the SH data in the world will not explain why the home sleep study shows there's no OSA when the in-lab study showed moderate OSA five years ago. And there's been no change in weight for lifestyle.

It's also important to note: An AHI = 0.0 on a random night using CPAP with the pressure set to 4cm is NOT proof that you don't have OSA. It might be that you don't have OSA. Or it could be that you've got OSA but only need minimal pressure to splint your airway open. On the other hand, if you use a CPAP at 4cm and wind up with a very high AHI that's mainly made up of OAs and Hs AND you slept ok with the mask on your nose, that's a pretty good indication that you probably do have OSA. SleepyHoosier could try digging the machine out of the closet and using it on minimum setting, provided his machine records efficacy data.

But in this case, I'm much more interested in the sleep studies' data. If that initial in-lab study scored hypopneas with arousal and the home study had no EEG, that's enough to explain the discrepancy in the two sleep study reports.

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05-16-2016 05:43 PM
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SleepyHoosier Offline

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Post: #7
RE: Home Sleep study questions
Thank you all so much for the replies! Its a lot to digest, so I hope I can fully understand it all! I will have to see if I can get a copy of my old sleep study. I thought I had it here at home and have been looking for it, but I can not find it! Went through a move since the last sleep study, so I hope it didnt get thrown out..Ill keep looking though.
If not, I suppose the hospital where I had it done could get me a copy of it. I know the sleep tech that I spoke to did state that she did get a copy of my last sleep study from a different hospital, so it will be passed on the the sleep Dr. when I see him next month.

I haven't used my cpap since last Aug. I am absolutely willing to give it a try again, but wasn't sure if I should since the home sleep study said no apnea. I didn't know if wearing it would be bad if I don't indeed have apnea? If I do try it again, should I leave it at the last settings that I had on it? If I remember correctly, I was getting AHI's in 7-10 area. Its a resmed S9 VPAP, so I do have the ability to pull up the data on it.

The home sleep study machine I had was called an ARES. sleepmedinc dot com/at-home is the webpage for it. According to the webpage, the ARES measures:
Blood oxygen saturation (Sp02)
Pulse rate (reflectance pulse oximetry)
Airflow (nasal cannula connected to a pressure transducer)
Snoring levels (calibrated acoustic microphone)
Head movement and head position (accelerometers)

I dont see anything about recording EEG on this unit that I used, so perhaps that is why I "passed" the home test. It makes me wonder how many people actually have sleep apnea that isnt being caught on these home studies.

Once again, I thank you all so much for your assistance!
05-16-2016 06:26 PM
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sonicboom Offline

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Post: #8
RE: Home Sleep study questions
I have it heard it said that the home sleep study test is not good for detecting mild OSA and can miss it entirely. It is why insurance companies generally insist on a home test first instead of a lab study because the home study will pick up the moderate to severe cases thereby obviating the sleep lab study. However, if your doc suspects OSA and the home study doesn't pick it up you should qualify for the lab study except that the lad study should be good for five years. Try the old machine - folks here can help you with any settings. Send some data and you shall have the answers you seek.

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05-16-2016 09:50 PM
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robysue Online
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Post: #9
RE: Home Sleep study questions
(05-16-2016 06:26 PM)SleepyHoosier Wrote:  If not, I suppose the hospital where I had it done could get me a copy of it. I know the sleep tech that I spoke to did state that she did get a copy of my last sleep study from a different hospital, so it will be passed on the the sleep Dr. when I see him next month.
I'd check with the place where the sleep test was done to make sure that they do indeed forward the results of the previous study to the new sleep doc. He needs to see that data.

Quote:I haven't used my cpap since last Aug. I am absolutely willing to give it a try again, but wasn't sure if I should since the home sleep study said no apnea. I didn't know if wearing it would be bad if I don't indeed have apnea?
Since all a CPAP does is blow some slightly pressurized air down your airway, it's not likely to do anything to a person who has no sleep apnea. There's a very small chance that CPAP pressure could trigger some central apneas in a person without any apnea since CPAP pressure can trigger central apneas in a small percentage of people with OSA. If you watched the data for CAs you'd be safe enough using your CPAP machine if you want to experiment with seeing whether using it addressed any of your sleep issues.

Quote:If I do try it again, should I leave it at the last settings that I had on it? If I remember correctly, I was getting AHI's in 7-10 area. Its a resmed S9 VPAP, so I do have the ability to pull up the data on it.
Do you happen to remember why you were put on an S9 VPAP instead of just an S9 CPAP or S9 APAP? Most people with a diagnosis of simple OSA don't wind up on a bilevel like a VPAP unless there is some kind of issue. However, it is possible to be switched to a bilevel simply because you complain about not being able to exhale against the pressure or because you complain about too much air in your stomach. Or people get switched because they continue to experience a too high treated AHI on CPAP/APAP.

Pull the old data and look at it. You want to know what the CAI was vs the OAI + HI. If most of your treated AHI was OAs and Hs, that might explain why using the S9 VPAP didn't really help very much: Therapy wasn't yet fully optimized. On the other hand, if the CAs made up the bulk of your events while using the machine, then you might be in that small group of PAPers who experience some problems with pressure induced CAs.

Quote:The home sleep study machine I had was called an ARES. sleepmedinc dot com/at-home is the webpage for it. According to the webpage, the ARES measures:
Blood oxygen saturation (Sp02)
Pulse rate (reflectance pulse oximetry)
Airflow (nasal cannula connected to a pressure transducer)
Snoring levels (calibrated acoustic microphone)
Head movement and head position (accelerometers)

I dont see anything about recording EEG on this unit that I used, so perhaps that is why I "passed" the home test.
Looks like that particular test might have a very difficult time diagnosing a hypopnea with arousal. The nasal cannula would pick up on the decreased airflow in a hypopnea with arousal and it would also pick up on the subtle changes in airflow that indicate growing resistance in the upper airway. But whoever scores the data would have to then search for so-called "recovery breaths" to infer an EEG arousal did take place. And if they weren't looking for RERAs or hypopneas with arousal, they might not bother looking for the recovery breaths. You need to ask the whether the home test required an O2 desat to score a hypopnea.


Quote:It makes me wonder how many people actually have sleep apnea that isnt being caught on these home studies.
The problem is that Medicare defined definition of a hypopnea that disagrees with what the sleep medicine community as a whole tends to prefer.

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05-16-2016 09:50 PM
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SleepyHoosier Offline

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Post: #10
RE: Home Sleep study questions
Hi RobySue,
Thanks again for your reply! The s9 vpap wasn't my original Cpap after my first sleep study, I bought that on my own last year after finding a deal I couldn't pass up. My previous Cpap was a basic model with no data capabilities ( at least that I could get at). Since I had so much trouble being compliant, someone recommended that I try a Bipap. I will try to pull some old data when I get home.
05-17-2016 02:21 PM
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