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Sleep Clinic doesn't score RERAs? What?
#1
Sleep Clinic doesn't score RERAs? What?
I just went for a CPAP tirtration study because I never had one when getting my CPAP 3 years ago and still sleep poorly. In talking with techs, they said they don't score RERAs anymore because the American Sleep Medicine Association or whatever it's called doesn't recommend it in their guidelines anymore. That seems pretty dumb to me. The tech explained that a RERA wouldn't be scored unless it was at least 10 seconds and had a sleep stage change with a 10% decrease in flow and 4% oxygen desat, or some specific number criteria like that and in the end it "ends up a wash" so no reason to score them. I don't understand. This doesn't make sense to me.


This seems very specific criteria, but why in the heck would these not be recorded and scored as part of RDI? If you are having some flow restriction and rouse, but it's not a hypopnea or apnea, it sure seems like that should be noted because you didn't naturally rouse still and it was breathing related. This seems crazy to me. Has anyone else heard this? I was told there is no RDI anymore and isn't in the report. They can notice a RERA during titration and can adjust pressure in response to it, but it won't be scored.
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#2
RE: Sleep Clinic doesn't score RERAs? What in the hell?
In a word, insurance. I'm sure this policy changes by sleep clinic, but the only reason these guys exist, at least in their mind, is to demonstrate the subject has an insured condition. Sleep clinics have also been known to ignore chronic low SpO2. If they can't score insurable "events" many tests are just interpreted as you don't have a problem. Flow limitation in my opinion is a significant problem in many people, that disrupts sleep and results in low oxygen saturation. This is the defining characteristic of upper airway restrictive syndrome UARS. Most insurance does not cover it, so most clinics don't score it.

With specific regard to flow limitation, the criteria for judging it may not be part of the protocol. The criteria you listed above like a x% decrease in flow and 4% desaturation is the definition of hypopnea or hypopnea. I don't think a 10% decrease is specifically looked at, but over 40% is, and over 70%.

We can disagree with it all we want, but a smarter approach might be to request or demand the sleep study protocol before we submit to it. Sleep study protocols must identify the objectives, methods and events that will be scored, as well as the criteria against which they are evaluated for success or failure. Doctors can order studies with modified protocols and objectives but rarely do. I don't recall anyone on this forum ever having a protocol ahead of taking a test. This sleep science stuff is really weird because every other medical test and procedure has clear methods, protocols and benchmarks that anyone can look at before taking the tests.
Sleeprider
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#3
RE: Sleep Clinic doesn't score RERAs? What in the hell?
reality meets the road. First off a Doctor has access to the entire sleep data not just the report that in all reality was created just for insurance to justify the best? treatment CPAP. The Doctor and patient knows that they have sleep Apnea before the testing. They need proof and settings. If you don't want insurance to pay for the equipment then you don't need a study. The Doctor can write a script for an Auto CPAP and you can go out and by one. no study needed.

If there are additional things going on beyond OA/CA then the Doctor can look at the raw data.

RERAs and UARs are not reported because the insurance company does not need them to okay the equipment.
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#4
RE: Sleep Clinic doesn't score RERAs? What in the hell?
(09-19-2018, 07:01 PM)PoolQ Wrote: reality meets the road. First off a Doctor has access to the entire sleep data not just the report that in all reality was created just for insurance to justify the best? treatment CPAP. The Doctor and patient knows that they have sleep Apnea before the testing. They need proof and settings. If you don't want insurance to pay for the equipment then you don't need a study. The Doctor can write a script for an Auto CPAP and you can go out and by one. no study needed.

If there are additional things going on beyond OA/CA then the Doctor can look at the raw data.

RERAs and UARs are not reported because the insurance company does not need them to okay the equipment.

Not exactly true. Unless the sleep doctor has data, in his professional capacity, he can't write a script for the machine. 

The problem with eliminating RDI from calculation is that you eliminate women from access to Xpap machines as women can have a high RDI and a low AHI (as I do).
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#5
RE: Sleep Clinic doesn't score RERAs? What in the hell?
Why only women? I started by having only RDIs and it took 3 more years before I developed more apneas. That's why I'm mad at this. I am probably having more RDIs still and they won't be included. They said I was way over pressured, I was at 17 with EPR 3, which seemed to offer the best AHI, then sleeprider was helping me fine tune it, Had the titration and they said I'm so far over pressured and they had me at 7 with EPR 3 the whole night. I haven't got the report yet but I want to see it, they said I slept almost the whole time after taking a remeron, which was about 11 hours. But I recall waking up a lot and tossing and turning all the time. Possibly from RDI, especially at such a low pressure, but now I won't even know!
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#6
RE: Sleep Clinic doesn't score RERAs? What in the hell?
(09-25-2018, 08:56 PM)sventory Wrote: Why only women? I started by having only RDIs and it took 3 more years before I developed more apneas. That's why I'm mad at this. I am probably having more RDIs still and they won't be included. They said I was way over pressured, I was at 17 with EPR 3, which seemed to offer the best AHI, then sleeprider was helping me fine tune it, Had the titration and they said I'm so far over pressured and they had me at 7 with EPR 3 the whole night. I haven't got the report yet but I want to see it, they said I slept almost the whole time after taking a remeron, which was about 11 hours. But I recall waking up a lot and tossing and turning all the time. Possibly from RDI, especially at such a low pressure, but now I won't even know!

And the missed opportunity here is to understand the role of pressure support (EPR) and why it helps RDI and UARS.  With bilevel therapy we can take people down in EPAP pressure to control OA, but then add the pressure support to eliminate hypopnea flow limits and snores.  If only we could use bilevel where we see these events!  The worst case is a CPAP or auto CPAP that doesn't have the bilevel capability like Philips.   In your case, we were starting with the doctor's recommendations, added EPR to resolve the flow limits, and had not yet reached the point where we start to reduce pressure to the lowest effective pressure.  It's a perfect excuse to ask your doctor, "why am I not on bilevel?"
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#7
RE: Sleep Clinic doesn't score RERAs? What?
A Doctor can write a medical necessity letter when ever they want (I know for a fact as they did this for me). the insurance company never sees the data and the data is only there to backup the doctor. It's always better to have the sleep report. Personally I got oxygen without any testing for it at all, just said I had problems at altitude and I got a script for oxygen. Of course insurance would not pay for it and that is typically the problem.
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#8
RE: Sleep Clinic doesn't score RERAs? What?
I basically told my doctor everything you said Sleep and showed them my data to back it up and my breath curve. I also asked the techs how and when they determine if someone needs bipap, they said if someone can't tolerate CPAP, but like, if someone is constantly waking up with an RDI but before an apnea, that doesn't look like CPAP intolerance, but also not helping. I asked them that and they just gave answers that sounded wrong to me. They at least did say my breath curve should be rounded smooth, so when I get the report I want to see the raw data fully.

Honestly the sleep techs seemed more knowledgeable than the doctor. When I explained everything to the doctor they just kept saying "uh huh", "ok", with no rebuttal if it was wrong, or confirmations. Seemed like they weren't versed enough to make a comment, the techs were able to answer all my questions and comment on my statements more thoroughly. We'll see what the report says, but frankly it would be another encounter where a doctor really disappoints me, They are supposed to be the most knowledgeable and again proving to be far from it.
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