I have been issues snoring for years, intermittently holding my breath according to my wife, waking up tired, excessive daytime sleepiness, and hypothyroidism. Went to my PCP and he referred me for a sleep study. Insurance would not cover an attended sleep study, so I had an ambulatory study performed. Additional info…39 y.o. male, 245 lbs, neck circumference 16 inches. Epworth sleepiness scale score 7.
Below is my report from the neurologist who read my sleep study.
Variables monitored included oral and nasal air flow, thoracic and abdominal effort, oxygen saturations, heart rate, snoring, and body position. Sleep time was calculated on patient diary, recorded snoring, respiratory events, and event markers. Total monitoring time was 486 minutes with approximate sleep onset latency of 23 minutes.
There were a total of 31 respiratory disturbances. Out of these, 19 were obstructive apneas with mean duration of 16 seconds and longest duration of 23 seconds. Respiratory event index (surrogate for apnea/hypopnea index on attended sleep study) of 4.3. Oxygen saturations were in the low to mid 90’s when there were no respiratory disturbances and in the mid 80s through high 80s with respiratory disturbances. Lowest saturation of 85%. Mean heart rate was 60. Mild to very loud snoring was present for 20% of total recorded time.
Interpretation:
No evidence of sleep related breathing disorder like obstructive sleep apnea on this ambulatory home sleep study. Respiratory event index of 4.3. Lowest Oxygen saturation of 85%.
Mild to very loud snoring was present for 20% of total recorded time.
Recommendations:
Since the home sleep study was negative, if there is ongoing clinical suspicion for obstructive sleep apnea, can consider attended in lab sleep study in split night criteria ir criteria met.
Weight loss will help.
So with all of that being stated, is there enough evidence to jump to the CPAP versus getting an in lab study? I have a high deductible deal and the study will be out of pocket. I can swing that, but if not necessary, I’d rather spend the money on the CPAP which will be out of pocket as well…
Any advice on the next step would be great. My PCP has been kinda ambiguous.
Hi Andrew. Austin asked me to chime in on your post because we trained together in school and instead of becoming super strong like him, I decided to remain mediocre and instead devote my time to studying all things relating to Hypnos.
As Michael Ray would say… there’s a lot to unpack here (don’t worry, I love that guy, and he knows it). I’ll try to get through your post in pieces to make it easier for folks to follow along. In general, I would say that there’s more investigating to do, so if you want a quick answer, unfortunately there often isn’t one when it comes to sleep and your best bet is to find a sleep physician or psychologist who will sit down and break things down more carefully.
You hit a lot of points here, mostly subjective and some mildly helpful objective points that might clue us in to you having a sleep problem. The most important things that you mentioned are that you snore, and that your wife has observed apnea – some studies would suggest these along with the sleepiness that a patient reports are often the stronger predictors of sleep disordered breathing, most commonly sleep apnea. Some other really important information that’s missing: your BMI (and arguably because you’re posting in this forum, your waist circumference) and have you been told you have high blood pressure. For those of you wondering if you’re at risk for sleep apnea, I would suggest you complete a STOP-BANG questionnaire on yourself (The Official STOP-Bang Questionnaire Website) and if elevated talk to your doctor. Andrew, as you can see we’ve gotten most but not all of those variables from your history. A few comments I will add, you mention hypothyroidism… is it treated or if it is have you had follow up labs to verify you’re on the right replacement dose? Lastly, you mentioned that you have excessive daytime sleepiness, but your Epworth was 6 – generally an Epworth ~14 or higher are suggestive of abnormally tired. So at face value your Epworth is normal, and it would be reasonable to ask you how does your sleepiness during the day present?
At the moment, I do not practice in a private-insurance model, so unfortunately my advice regarding how to navigate the system will be limited. It’s not totally unreasonable to have offered you a home sleep test. Most people sleep more comfortably with them and the tests can accurately diagnose the more common sleep disordered breathing reasonably well with one caveat: the person undergoing the test should have a relatively high pretest probability of being positive. In-lab and level-2 sleep studies (i.e. you get hooked up by a tech/go home and sleep or get hooked up and sleep in a lab without a tech observing you) are better at picking up more positives because there’s more data to interpret from – (EEG, leg movements, video, etc.) In other words, even though you were negative on this study, you surely could be positive on the in-lab test if you have more arousal based respiratory events that might have been missed because the home test didn’t have EEG. I always reserve home studies for patients who are likely to be positive, and for those that are negative but I still worry about sleep apnea, I push for getting the in-lab study.
The information you put up is a standard home sleep test report. I don’t think there’s anything major missing from the report that would make me question its validity. Although you have respiratory disturbances with associated desaturations, with snoring, I agree that it seems you didn’t meet the criteria for OSA (right now) from what I’m reading.
Your question about skipping the in-lab study vs. going straight to CPAP is far more complicated than you’re asking based on the info provided above. Yes, you have risk factors, but you don’t have a diagnosis yet and there are a lot of other factors that could be contributing to how you are feeling. There are a lot of biological/psychological/social factors that can be at play (yes, the BPS model is far more widely applicable than just what you guys have seen discussed with Mike, Jordan and Austin). Some basic questions that would be reasonable to ask you would be: What’s your sleep schedule like – are you getting 7-8 hours of uninterrupted sleep? are you maintaining the same sleep schedule 7 days/week? if you’re waking up in the middle of the night how many times, and for how long? What’s sleep environment like (i.e. light, noise, temperature and electronics in the bedroom)? How are things going, any major new stressors or catalysts recently or before your symptoms began? Alcohol and other medication use? The list goes on and honestly your responses would determine the subsequent follow up questions.
I don’t blame your PCM for being vague – a lot of primary care doctors aren’t comfortable or familiar with these questions; I certainly wasn’t until I got the extra training. The point is, there more to diagnosing a sleep problem than one might initially think. The first step is getting asking the questions, possibly getting screened for OSA, which you’ve gone ahead and started. If you’ve only gotten a home test that was ordered by your PCM, then the next reasonable step would be to see about talking with a sleep specialist IMO so they can go through the things I’ve mentioned as contributors to your concern. They can help you decide what the next best step would be. Jumping straight to CPAP is not a good idea, and could possibly make your sleep have worse quality than currently (if you actually don’t have sleep apnea or mild at best, wearing a mask that’s giving you positive airway pressure would only make things worse). Unfortunately there’s a spectrum of people who respond to treatment, and there isn’t enough information to know that you would right now.
Thanks for taking the time to address this. The reason I posted on here was I figured I would get a thorough and thoughtful answer which I certainly did.
To answer some of your questions of me:
BMI 33.3. Waste is 41 inches.
My last thyroid panel was in November:
fT4 1.46 ng/dL (0.82 - 1.77)
TSH 2.26 uIU/mL (0.450 - 4.500)
Thyroglobulin Ab <1 IU/mL (0.0-0.9)
TPO Ab 10 IU/mL (0-34)
fT3 3.2 of/mL (2-4.4)
I take three grains armour thyroid.
I did the STOP-BANG and scored a 4 (the one question on being tired…I answered yes as I get worn out easily, fatigue, but I don’t ever fall asleep when talking to someone).
My blood pressure has ranged between 120-130/80-85
With regards to sleep patterns this can be very erratic with my job. I am a large animal veterinarian and on top of regular day scheduled appointments, I also take emergency duty and am on call every other week. Some nights I sleep 8 hours, other times it’s 0-8 and any time period in between. My weeks off duty definitely are more structured at least. But I don’t have a routine sleep pattern that’s for sure.
I wake up anywhere from 1-3 times a night usually because I have to take a leak.
My my room is almost pitch black, as I don’t sleep well with lights on. There’s a tv in the room which I do fall asleep to on occasion. Phone in room otherwise and a clock.
I do not drink. The only medication I am on consistently is the thyroid medication. I do take singulair seasonally. Otherwise I don’t take anything.
Stressors etc pretty much the same stuff for the last 15 years so nothing new and nothing terrible.
Thanks again for your advice. I do appreciate it. You’ve shed some light on a subject I’m not that familiar with. I certainly do not want to jump in headfirst or skip steps. Just looking for some clarity, which you have provided me.
Sure, I think you’ve identified enough risk factors in the OP as well as some others here that would warrant a discussion with a sleep doctor. Not an emergency, which is a nice thing about Sleep Medicine. Some other learning points from your second post:
Nocturia (frequent urination at night) can be an additional risk factor for OSA (due to wide changes in intrathoracic pressure that translate to the heart causing perception of “volume overload” which can cause release of a signal that would cause you to urinate more frequently) although this is somewhat controversial/theoretical.
Irregular sleep schedules like the one you typically maintain due to your job are a common reason for the MOST COMMON cause of daytime fatigue/sleepiness, which is INSUFFICIENT SLEEP. This is where a sleep diary would be helpful for you/your doctor to gain perspective on your sleep patterns to identify potential maladaptive behaviors. Sometimes we track this with an Actigraph watch (think medical grade FitBit). From my understanding, insurance coverage of this kind of test can vary, but it’s frequently used in sleep clinics to help assess for insufficient sleep, or circadian misalignments (i.e. your life does not conform to your internal biological clock). Either way, if you are having variable bed times and sleep times that are not consolidated, it would be reasonable to think that in general your sleep is perceived as poor quality overall. Shift work is a common problem that can be managed short term with sleep aids, melatonin/light therapy or stimulants depending on the situation. In general, the fix is to find a way to regulate the sleep schedule.
In terms of sleep hygiene (Google that), things look okay (except the TV thing, I would get it out of the bedroom and find another way to relax at night). Similar to point 2, our behaviors at night can really affect our ability to allow sleep to happen. If you want to go deeper into the rabbit hole, I would recommend checking out the Spielman Model of Chronic Insomnia (Insomnia: Practice Essentials, Background, Anatomy). It would help you (and hopefully others in this forum) to understand that there are many factors that play into one’s difficulties with sleep (including predisposing factors, precipitating factors, and perpetuating factors — very similar to the BPS concept). A sleep doctor or psychologist would be able to help you work on the perpetuating factors/maladaptive behaviors like keeping an irregular schedule.
Honestly, in this context I wouldn’t feel comfortable recommending anything specific to your case other than considering seeing a sleep physician or psychologist to help you figure out what the next step is. It might cost a bit up front but would hopefully help you in the long term.
Thanks Nick for all of the information and shedding light on a complicated subject. I will get with my doctor and see about getting a referral with a sleep specialist and go from there. In the meantime I will make some changes as you have described. Will keep you all posted.