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Receiving a sleep test for 13 y/o ADHD
#1
Question 
Receiving a sleep test for 13 y/o ADHD
Hello all. I've been spending a part of my day reading through your forums and have found them to be most informative. I am currently waiting on a printed report for my 13 year old son, who recently had an in-clinic sleep assessment performed. I've long suspected sleep issues, even as a baby he would gasp or hold his breath while sleeping. He's severely short for his age (~5th percentile) but his weight tracks normally (>40th percentile), which is something that can be attributed to sleep apnea. That combined with his 3rd grade diagnosis of ADHD for poor concentration, poor organization, poor working memory, agitation, and elevated anxiety resulted in us FINALLY getting to see a specialist. We've taken 3 rounds of nasal steroids (Nasonex) and he underwent a tonsillectomy this summer. He is still waking during the night, snoring, and feeling tired all day.

I had a phone call with his doctor this morning to review the results and the basic run-down is that while his sleep efficiency index was "suboptimal" and total sleep time "inadequate", his AHI was 0.7 and both his O2 and CO2 levels were normal. However, his RDI was "borderline", whatever that means, and there didn't seem to be an intention to push for any sort of follow-up. I've asked for a hard copy of the report to review, and am curious what things in particular should I be looking for to determine as a parent if I need to lean into the health care system a little harder to get some answers/action. I suspect the events that his mother and I have been witnessing may appear as RERAs on the study as opposed to full-on apneas or hypopneas, hence the difference between AHI and RDI.

Is there a specific graph or chart I should look for before I go back to them with any questions? What kind of questions can I ask regarding the "bad things" vs. "good things"? I'm hoping to get a copy of the results in the next few days to share but want to make sure I'm prepared in case there is something specific I should be watching for.
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#2
RE: Receiving a sleep test for 13 y/o ADHD
   

Update: here's a sort-of redacted copy of the study. I'm not too sure what any of this means in the context of a child about to turn 13. Is there anything here that would indicate something worth looking at?

The notes from the clinic to the physician:

Level 1 study conducted, does not support OSAS diagnosis. Mild sleep disturbances may be associated with flow limitations. Patient will be referred back to specialist office. Patient may benefit from upper airway surgery to help improve patency. If there is no indication, 16-week trial of daily nasal corticosteroids and Singulair (5mg, PO, daily) would be helpful.

Interpretation:

Total sleep time inadequate. Sleep efficiency suboptimal. Sleep latency normal. R stage latency increased. N1% increased, N2% decreased, N3% increased. R% decreased.
AI normal. PLMS normal. AHI normal but RDI borderline increased. 
SpO2 Nadir insignificant. % total sleep time with PCO2>50mmHg normal.
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#3
RE: Receiving a sleep test for 13 y/o ADHD
There are recorded 3 Hypopnea, these are at 50-80% the strength of regular apnea. 16 PLM with 15 of these linked to an arousal. 52 arousals, probably overall. Sleep efficiency of 57.9%. This means this is very poor sleeping, lots of arousals, not necessarily related to apnea but PLM adds some.

About RDI: respiratory disturbance index (RDI) — or respiratory distress Index — is a formula used in reporting polysomnography (sleep study) findings. Like the apnea-hypopnea index (AHI), it reports on respiratory events during sleep, but unlike the AHI, it also includes respiratory-effort related arousals (RERAs).

Myself, I wouldn't just accept it as not doing anything. Tell them they best decide how this is treated as it's unacceptable to do nothing.
Dave

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#4
RE: Receiving a sleep test for 13 y/o ADHD
his 57.9% sleep efficiency and 5.2 arousals per hour need to be addressed more than disordered breathing. at least some of that is due to periodic limb movement (plm), which I would have thought unusual enough in a young man to raise your doc's eyebrows. but few docs seem to care to address plm so it'll be up to you to a) press for some treatment for it and b) try to determine what else is causing his arousals. a video camera is the best way to see what's going on. the data from a cpap machine, if he can try one, might provide some insight as well. I've had lifelong adhd, sleep apnea since at least my teens and plm for I don't know how long. while my apnea is well managed, plm is more difficult and I'll state unequivocally that for me plm is darn near as exhausting as my untreated 72 apnea/hour. I firmly believe that sleep deprivation from any source significantly exacerbates if not causes adhd.
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#5
RE: Receiving a sleep test for 13 y/o ADHD
Thank you both for your insights. We've been struggling with his sleep since he was born and no one has ever been able to crack it. He went to bed at 10pm last night and is still sleeping (9:38am, in-service day at school). He'll still wake up after 12 hours and be completely sacked out. The sleep efficiency, PLM, and arousal scores are pretty indicative of his usual night's sleep - we can hear him clunking up against the wall every once in a while so he's got to be thrashing around in there.

We've used a Fitbit previously for tracking his sleep but it's not great - any gap in movement is recorded as sleep it seems. But he's still averaging 40+ disturbances in their software as well, I wonder if it would be worse if I stuck it on his ankle for a night.

Our hope was that the tonsilectomy would open up his upper airway and remove any blockages, but there's still a few hypopneas and a RERA in 4 hours of sleep. On the OR table they made the decision not to remove his adenoids as they looked quite small and after the tonsils were removed they observed him under sedation for some time and noticed no significant drops in O2 (which I think is indicated on the report, lowest O2 of 96% and a mean of 98% is great) or difficulty breathing.

My question is if the arousals may be smaller gaps in respiration (don't qualify as apnea/hypopnea or RERA), would he still benefit from CPAP or BiPAP therapy? I'm reading some articles indicating that CPAP can be effective at treating PLMS as the PLM is associated with a respiratory event. I'm still compiling all my data, and we've got to bring him for blood work (ENT specialist wants to see iron and thyroid function - iron may be indicative of PLMS) but this information so far is excellent. Great community.
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#6
RE: Receiving a sleep test for 13 y/o ADHD
Your son's daytime experience tells us something is not right, and he is averaging over 5 arousals per hour, most associated with respiratory effort and some with periodic leg movement. That adds up to very disrupted sleep. I don't know what the normal REM percentage is for someone his age, but for an adult, 8% would be very low.

It sounds as though the ENT is following up on PLMS, which is good. From the nasal spray and Singulair, I gather your son experiences nasal congestion. Is that correct? Has he been tested for allergies?

I would recommend that you press for some follow-up on this: "Mild sleep disturbances may be associated with flow limitations." In particular, ask about Upper Airway Resistance Syndrome, or UARS. Take a look at this:

http://www.apneaboard.com/wiki/index.php...ome_(UARS)

and this:

https://stanfordhealthcare.org/medical-c...drome.html
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#7
RE: Receiving a sleep test for 13 y/o ADHD
More confirmation, thank you! He has been allergy tested, no allergies. He had many severe ear infections as an infant to the point they were considering tubes, but they went away at age 5. The ENT originally wanted to remove his adenoids due to enlargement but we tried Nasonex treatment for 3 months and when he went under the knife for an adenotonsillectomy they decided to remove just the tonsils as his adenoids appeared fine (which was frustrating, but they did specifically monitor his breathing afterwards and found no disruptions as far as O2 levels).

I believe the Arousal Index number is incorrect, it is listed as 5.2 events per hour. But with 4 hours, 1 minute of sleep and 52 arousals, the correct number should be 13 events/hour, or 1 event every 4.5 minutes roughly.

We'll be getting his bloodwork done hopefully Monday since the clinics are packed lately. I'm interested primarily in the serum iron result as it can be an indicator of PLMS, especially with the PLMI being where it is. From there, I suppose we're looking at a possible UARS case as seeing if the ENT will push CPAP or something else. If they don't I do have a dentist locally who specialized in MAD for sleep problems like chin tuck, that might be my last resort if it comes to that.
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#8
RE: Receiving a sleep test for 13 y/o ADHD
Your son’s total sleep time was too short to rule out or confirm sleep disordered breathing. Ideally he should have another study with esophageal pressure manometry so that events can be detected during both nasal or mouth breathing (hypopneas and RERAs can only be scored during nasal breathing because thermistors cannot detect flow limitation with any accuracy). The current definition of arousal is also very flawed as it doesn’t include delta bursts as arousals as well as other phenomena. I’d give this paper a good read.
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