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Could you please help analyze my sleep study results? Pretty sure I need an ASV
#1
Could you please help analyze my sleep study results? Pretty sure I need an ASV
I've been back and forth with the doctor and team, and they all still think I need an APAP. *cough* *cough* insurance racket BS. I disagree but I'm not armed with information and data to prove it. Or my understanding of all of this is new. Could a seasoned vet on this forum take a look at my study results and give me some analysis and tell me what type of machine I need? My gut feeling is that I need an Resmed Airsense 10 ASV.

Let me know? Unfortunately because this is my first post, the board won't let me add a link or attachment, so my sleep study is copied below, thanks:




Progress Notes
Progress Notes by (blank) (blank) at 9/27/2021  3:30 PM
Message sent to Sleep Specialist to schedule acti-watch for patient.
(blank) (blank), MA
 
Progress Notes by (blank), MD, MD at 9/27/2021  3:30 PM
(blank) is a 33 year old male who is being evaluated via a billable video visit.  
 
The patient has been notified of following: 
 
"This video visit will be conducted via a call between you and your physician/provider. We have found that certain health care needs can be provided without the need for an in-person physical exam.  This service lets us provide the care you need with a video conversation.  If a prescription is necessary we can send it directly to your pharmacy.  If lab work is needed we can place an order for that and you can then stop by our lab to have the test done at a later time.
 
Video visits are billed at different rates depending on your insurance coverage.  Please reach out to your insurance provider with any questions.
 
If during the course of the call the physician/provider feels a video visit is not appropriate, you will not be charged for this service."
 
Patient has given verbal consent for Video visit? Yes
How would you like to obtain your AVS? Mail a copy
If you are dropped from the video visit, the video invite should be resent to: Text to cell phone: -
Will anyone else be joining your video visit? No
If patient encounters technical issues they should call 612-672-7266
 
 
Video-Visit Details
 
Type of service:  Video Visit
 
Video Start Time: 3:30pm
Video End Time: 4pm


Originating Location (pt. Location): Home
 
Distant Location (provider location):  M HEALTH FAIRVIEW SLEEP CENTER MINNEAPOLIS 
 
Platform used for Video Visit: AmWell
 
Virtual visit for review of sleep testing results.
 
Assessment:
- Moderate OSA (AHI 21.3, RDI 27.9) with sleep-associated hypoxemia.  Prolonged desaturations seen in supine REM.
- Rare PLM's on PSG
- Persistent muscle twitching / fasiculations arising from sleep and note from patient of other people with alopecia universalis reporting similar sleep concerns.  DDx is broad including PLM's, hypnic jerks, propriospinal myoclonus, unknown.
 
Plan:
- Start CPAP auto-titrate 5-15 cm H2O
- Actigraphy x 2 weeks to better assess sleep-wake pattern and if evidence of increased body movements during sleep
 
SUBJECTIVE:
(blank) is a 33 year old year old male.
 
Pertinent PMHx of ADD, obesity, HTN, depression, anxiety, alopecia universalis.
 
Appointment note mentions chronic insomnia, hypnic jerks, reportedly already practicing sleep hygiene.
 
7/19/2021 -he feels that he has had issues with insomnia and his sleep in general for many years, almost since birth.  But he was prompted to seek an evaluation at this time since working from home remotely with Covid and discussing with his family about their sleep in relation to his sleep potentially had issues.
 
He feels that he has had challenges with falling asleep and staying asleep for as long as he would remember, since childhood.  He did not necessarily identify this as an issue or abnormal since it has been this way for as long as he can remember.  But this recently changed after he was reading and talking with his alopecia universalis support group and had brought up about many different sleep disorders that have been linked with that, including hypnic jerks.  He then spoke with his parents about their sleep, and was surprised by how quickly they would fall asleep and in general lack of issues.  He does feel that his sleep affects him during the day but feeling more tired, but denies any inappropriate sleepiness.
 
Given the variability of the sleep, he finds it hard to describe his typical sleep pattern today.  He would give his sleep in general a grade of "C or C-", but on nights that he does not have perceived hypnic jerks that his sleep quality be closer to a "B or B-".  It appears that most nights he is going to bed around 11 PM, but time to fall asleep is unknown and unclear.  He feels that potentially 1 or more nights per week that he perceives little to no sleep while spending the entire night in bed.  He is also unclear about what time he gets up to start his day.  He does not seem to take regular daytime naps.
 
He has been trying to take his sleep more seriously, again discussing this with his alopecia support group.  He has purchased and started using a light box in the morning.  He has tried multiple over-the-counter sleep aids including melatonin in the past, but not felt to have appreciable benefit.  It is unknown the exact timing or dosage of these.
 
We discussed his reported hypnic jerks in more detail.  He reports he is predominantly happen as he is attempting to initiate sleep, occur most nights, and can seem to happen multiple times in a given attempt to fall asleep.  He describes this as feeling that he is falling.  He states that sometimes these can be visible, but other times have been very subtle work he does not believe other people would perceive the muscle activity.
 
He believes he does snore, but he is unsure if it is loud or regular.  He is unaware of any reports of observed apnea.  He has woken up with a gasping sensation before.
 
He was diagnosed with hypertension and started medications in his early 20s, there does not appear to be a concern currently for secondary hypertension.
 
Today - We reviewed the PSG results in detail.  We also discussed the unclear etiology of the jerky movements arising from sleep and potentially disrupting sleep.
 
ISI Total Score: 26
 
 
 SLEEP STUDY INTERPRETATION
DIAGNOSTIC POLYSOMNOGRAPHY REPORT
 
 
Patient: (blank), (blank)
Date of Birth: 6/5/1988
Study Date: 9/15/2021
MRN: 0007233408
Referring Provider: self
Ordering Provider: (blank) MD (blank)
 
Indications for Polysomnography: The patient is a 33 year old Male who is 6' 2" and weighs 245.0 lbs. His BMI is 31.4, Epworth sleepiness scale - and neck circumference is - cm. Relevant medical history includes chronic insomnia, ADD, obesity, HTN, depression, anxiety, alopecia universalis. A diagnostic polysomnogram was performed to evaluate for sleep apnea.
 
Polysomnogram Data: A full night polysomnogram recorded the standard physiologic parameters including EEG, EOG, EMG, ECG, nasal and oral airflow. Respiratory parameters of chest and abdominal movements were recorded with respiratory inductance plethysmography. Oxygen saturation was recorded by pulse oximetry. Hypopnea scoring rule used: 1B 4%.
 
Sleep Architecture: Fragmented, increased arousal index, supine REM was observed.
The total recording time of the polysomnogram was 532.0 minutes. The total sleep time was 454.5 minutes. Sleep latency was increased at 30.5 minutes with the use of a sleep aid (zolpidem 10mg). REM latency was 57.5 minutes. Arousal index was increased at 35.6 arousals per hour. Sleep efficiency was normal at 85.4%. Wake after sleep onset was 46.5 minutes. The patient spent 5.2% of total sleep time in Stage N1, 47.4% in Stage N2, 21.2% in Stage N3, and 26.2% in REM. Time in REM supine was 57.5 minutes.
 
Respiration: Moderate OSA (AHI 21.3, RDI 27.9) with sleep-associated hypoxemia.  Prolonged desaturations seen in supine REM.
Events ─ The polysomnogram revealed a presence of 25 obstructive, 71 central, and 1 mixed apneas resulting in an apnea index of 12.8 events per hour. There were 44 obstructive hypopneas and 20 central hypopneas resulting in an obstructive hypopnea index of 5.8 and central hypopnea index of 2.6 events per hour. The combined apnea/hypopnea index was 21.3 events per hour (central apnea/hypopnea index was 12.0 events per hour). The REM AHI was 25.7 events per hour. The supine AHI was 34.3 events per hour. The RERA index was 6.6 events per hour.  The RDI was 27.9 events per hour.
Snoring – was reported as moderate to loud.
Respiratory rate and pattern – was notable for normal respiratory rate and pattern.
Sustained Sleep Associated Hypoventilation – Transcutaneous carbon dioxide monitoring was not used, however significant hypoventilation was not suggested by oximetry.
Sleep Associated Hypoxemia – (Greater than 5 minutes O2 sat at or below 88%) was present. Baseline oxygen saturation was 93.8%. Lowest oxygen saturation was 77.6%. Time spent less than or equal to 88% was 5.9 minutes. Time spent less than or equal to 89% was 8.4 minutes.
 
Movement Activity: Rare PLM’s observed.
Periodic Limb Activity – There were 4 PLMs during the entire study. The PLM index was 0.5 movements per hour. The PLM Arousal Index was 0.5 per hour.
REM EMG Activity – Excessive transient/sustained muscle activity was not present.
Nocturnal Behavior – Abnormal sleep related behaviors were not noted during/arising out of NREM / REM sleep.
Bruxism – None apparent.
 
Cardiac Summary: Appears NSR.
The average pulse rate was 68.6 bpm. The minimum pulse rate was 48.9 bpm while the maximum pulse rate was 110.2 bpm.  
 
Assessment: 
Moderate OSA (AHI 21.3, RDI 27.9) with sleep-associated hypoxemia.  Prolonged desaturations seen in supine REM.
Rare PLM’s observed.
 
Recommendations:
Consider repeat polysomnography with full night titration of positive airway pressure therapy for the control of sleep disordered breathing.
Based on the presence of moderate obstructive sleep apnea and excessive daytime sleepiness, treatment could be empirically initiated with Auto─titrating PAP therapy with a range of 5 to 15 cmH2O. Recommend clinical follow up with sleep management team.
Patient may be a candidate for dental appliance through referral to Sleep Dentistry for the treatment of obstructive sleep apnea and/or socially disruptive snoring.
If devices are not acceptable or effective, patient may benefit from evaluation of possible surgical options. If he is interested, would recommend referral to specialized ENT-Sleep provider.
Advice regarding the risks of drowsy driving.
Suggest optimizing sleep schedule and avoiding sleep deprivation.
Weight management (if BMI > 30).
Pharmacologic therapy should be used for management of restless legs syndrome only if present and clinically indicated and not based on the presence of periodic limb movements alone.
 
Diagnostic Codes: 
Obstructive Sleep Apnea G47.33
Sleep Hypoxemia/Hypoventilation G47.36 
 
_____________________________________
Electronically Signed By: (blank) (blank), MD (9/26/2021)
 
 
 
 
 
10 point ROS of systems including Constitutional, Eyes, Respiratory, Cardiovascular, Gastroenterology, Genitourinary, Integumentary, Muscularskeletal, Psychiatric were all negative except for pertinent positives noted in my HPI.
 
Current Outpatient Medications
Medication
Sig
Dispense
Refill

zolpidem (AMBIEN) 10 MG tablet
Take 1 tablet (10 mg) by mouth nightly as needed for sleep .  Bring with you to sleep study.
1 tablet
0
 
 
OBJECTIVE:
There were no vitals taken for this visit.
 
Physical Exam 
 
---
This note was written with the assistance of the Dragon voice-dictation technology software. The final document, although reviewed, may contain errors. For corrections, please contact the office.
 
(blank) (blank), MD
 
Sleep Medicine
M Health Fairview Sleep Centers - University of MN  (612-273-3396)
M Health Fairview Sleep Centers - Hibbing  (218-362-6558)
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#2
RE: Could you please help analyze my sleep study results? Pretty sure I need an ASV
"The polysomnogram revealed a presence of 25 obstructive, 71 central, and 1 mixed apneas resulting in an apnea index of 12.8 events per hour. There were 44 obstructive hypopneas and 20 central hypopneas"

Given that it shows this quote, your Central Apnea are nearly 3x the Obstructive Apnea, Hypopnea are showing Central as well.

Later, during the medical assessment portion, it mentions mild OSA, rare PLM, persistent muscle twitching. They are blind to the Central Apnea and Hypopnea component. Centrals aren't even mentioned. Highlight and call the doctor out on this, respectful but not being deterred.

BTW, ASV is indicated when 50% or more of your events were Central. 3x the Obstructive Apnea. OK sounds like you have that part covered. The ASV treats all Apnea, both Central and Obstructive.

Find out from the doc, "What is your plan to address the high level of the Central Apnea and Hypopnea component? Are we planning on treating or ignoring these? ResMed's info tells me that pre-dominant Central Apnea are treated with ASV. Is an ASV Titration in the plans or not? Do you recognize that I have CA?"

If the answer is not to be concerned or don't worry about Centrals, you will have problems with this doctor. You may them need to fire and replace with one that knows how to treat CA instead of pretending they don't exist.

Here's ResMed's chart for devices:

[attachment=38348]
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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#3
RE: Could you please help analyze my sleep study results? Pretty sure I need an ASV
Gotcha, Thanks for much for this info! I will definitely be more direct than I have been to my doctor about these centrals! And I will ask the sleep tech what they plan to do for my centrals!
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#4
RE: Could you please help analyze my sleep study results? Pretty sure I need an ASV
Quote:The polysomnogram revealed a presence of 25 obstructive, 71 central, and 1 mixed apneas resulting in an apnea index of 12.8 events per hour. There were 44 obstructive hypopneas and 20 central hypopneas resulting in an obstructive hypopnea index of 5.8 and central hypopnea index of 2.6 events per hour. The combined apnea/hypopnea index was 21.3 events per hour (central apnea/hypopnea index was 12.0 events per hour). The REM AHI was 25.7 events per hour. The supine AHI was 34.3 events per hour. The RERA index was 6.6 events per hour.  The RDI was 27.9 events per hour.

I'm on the same page as Dave. You have a very significant central sleep apnea component.  Rarely, this clears up when on CPAP, however in most cases where CSA is present prior to starting therapy, we see obstructive events mostly resolve on CPAP and the central component remains, and is sometimes worse.  Insurance generally requires a patient to complete a trial on CPAP and fail before they will consider upgraded therapy.  A shortcut may be to discuss with your doctor that it with the significant number of central apnea and hypopnea, the diagnosis of obstructive sleep apnea (OSA) is not appropriate, and the study clearly points to complex sleep apnea syndrome (CSAS). This diagnosis could be used to justify a clinical titration study.  The study should specify a titration of CPAP moving to bilevel ASV if CPAP fails to demonstrate efficacy. 

I'm going to give you a link to the Resmed Sleep Lab Titration Protocols.  Your job is to look at the different types to positive air pressure (PAP) therapies and understand what they are intended to treat.  You will see CPAP, VPAP (bilevel), ASV (adaptive servo ventilation) and VPAP ST and iVAPS.  You should focus on CPAP and ASV.  In all cases, there is a "decision-tree" for how to perform titration, and where a patient continues to have central sleep apnea, the recommendation is to move to ASV.   This should give you enough background to discuss the issue with the doctor.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

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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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#5
RE: Could you please help analyze my sleep study results? Pretty sure I need an ASV
I was prescribed an Auto CPAP in 2017. Until the recall and my sister’s issues with central apnea and AFIB, I was complacent and assumed the sleep medicine people knew what they were doing. I then started watching YouTube videos by CPAP Reviews (Nicko) and LankyLefty27 (Jason), and discovered Apneaboard. I reviewed my sleep study and found that it showed mixed (complex) apnea from day 1. I then loaded the SD card into OSCAR and discovered that “treatment” on the Auto CPAP was a total train wreck, with AHI running to 30. The APAP responded to central events with pressure pulses, to little avail.
I will post examples in my therapy thread for your education about what to avoid.

I also looked at my sister’s SD card on OSCAR and saw that her ASV machine with manual timing control was treating her 100% central apnea properly.
I found a 2 year old ASV machine on EBAY and bought it. My results are variable, but my tidal volume and O2 saturation are very stable.
I will post more examples from the ASV in my thread for comparison. The COVID Omicron has increased my AHI recently.
In dealing with the Sleep Medicine - Insurance complex, it pays for you to become educated about your options. This board and the YouTube videos have been very helpful resources.

Trust, but verify - but maybe not in that order.
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