Sleep Study and Alternatives

For people exploring sleep apnea and for their healthcare professionals, peer coaching article #3, updated 22 November 2011

Sleep Study Options
An overnight sleep study in a sleep lab is the gold standard of diagnosis. It’s a very sophisticated way of testing for sleep apnea – obstructive (the most common kind), central (more rare), or mixed or complex (both kinds) – by checking airflow in your throat, snoring, and the effort your chest makes to breathe in various positions and in different stages of sleep. A lab study may also check for Restless Leg Syndrome, the amount of oxygen in your blood, and your heart rate and rhythm. If your doctor orders a sleep study, insurance or Medicare should pay for it. A split night sleep study may cost between $1,500 and $5,000. Check your insurance coverage and whether pre-approval is necessary..

1. In the most common, one-night “split study,” half the night is spent measuring your sleep, creating a polysomnogram (PSG) which is later interpreted by a physician. If you seem to have Obstructive Sleep Apnea (OSA), the second half of the night is spent using a CPAP (Continuous Positive Airway Pressure) machine to find the best airflow pressure setting for you.

Advantages of a split study: lower cost, since it’s only one night. If the sleep technician gives you a mask, you get fast feedback in the middle of the night that you most likely have OSA. Later, upon receiving the report, you have a pressure setting for a doctor’s prescription for a CPAP machine.

Disadvantages: if you have concerns about falling asleep in a lab setting, or worry about wearing a respiratory mask for the first time, you may not fall asleep or have poor quality sleep, resulting in an inconclusive outcome or poor study. The sleep technician has less time to record your sleep cycles to do the sleep study and less time to find an effective titration setting, a slow trial-and-error process which requires your sleep.

2. A second option is a two-night study. It’s the same process as a split study, but a full night is used for each part. The first night is a baseline study of your sleep. The second night is a titration study to establish a CPAP pressure setting.

Advantages of a two-night study: Alleviates mask fear on the first night since no mask is needed, supporting better sleep and a better study. The technician has plenty of time to record sleep cycles and on the second night, plenty of time to try various pressure settings during the titration.

Disadvantages: may be twice the cost of a split study. It will take additional time to schedule the second study and get a pressure setting, which could delay the start of treatment.

3. An unusual alternative third option is a single baseline study and use of an APAP machine instead of a titration study to determine pressure settings. After a baseline study report of OSA (the first night), if CPAP seems to be the best treatment, and if you are a candidate for an APAP (an Auto-titrating Positive Airway Pressure) machine, you can get a prescription and machine long before a second night study. In fact, with an APAP machine and software and helpful doctor, it may not be necessary to have a second titration study. The APAP machine can be used to determine pressure settings instead of sleep lab titration.

Research:

American Journal of Respiratory and Critical Care Medicine, Can Patients with Obstructive Sleep Apnea Titrate Their Own Continuous Positive Airway Pressure?
http://ajrccm.atsjournals.org/cgi/content/full/167/5/716 Quote: Home self-titration of CPAP is as effective as in-laboratory manual titration in the management of patients with OSA.

Advantages of a baseline study and APAP: lower cost, since it’s only one night. Alleviates mask fear during the study since no mask is needed, supporting better sleep and a better study. The technician has plenty of time to record your sleep cycles. If you do require a second night titration study, it can still be done later. Requirements: 1) the physician’s decision about the efficacy of APAP machine auto-titration settings instead of sleep lab titration. 2) use of an APAP machine able to record daily details, machine setup manual, and software. 3) physician and patient experimentation to find optimal pressure settings. 4) frequent software downloads by the patient (or a cooperative Durable Medical Equipment provider, DME). Remember, the sleep lab results are the gold standard, held to be the most effective means of determining CPAP machine pressure settings. The questionable trade-off may be better sleep lab equipment versus better patient comfort and resultant sleep in their own bed, and the ability to trial various pressure settings over several nights.

The deciding factors among the sleep study options may be a combination of your medical and psychological needs, your physician’s advice and support, and your insurance or Medicare coverage or your ability to pay out-of-pocket for APAP machine software. Discuss your needs with your physician and find out what your insurance company or Medicare supports and requires. Insurance companies tend to pay for a sleep study and CPAP equipment, because it’s more cost effective than paying for treatment of heart failure or stroke, treatment of car wreck injuries, and other serious health conditions resulting from untreated sleep apnea. Medicare usually requires a sleep study before paying for CPAP equipment. Does your insurance company have the same requirement? What impact do your deductible and co-pay have on your costs for various options? If possible, it may be more expedient to avoid scheduling your sleep study during the last quarter of the year, since the sleep lab may be overly busy then because people wait to schedule testing until they have reached their calendar year insurance deductible. However, if sleep apnea is suspected, it’s best to be tested and get your equipment as soon as possible.

Sleep Study Results

Know these three simple definitions from the sleep study report:

Apnea. The Greek word “apnea” means “without breath.” You stop breathing during sleep for ten seconds or longer.

Hypopnea. There is airflow through your throat but at a much reduced level, which leads to not getting enough oxygen. It’s abnormally shallow breathing lasting at least ten seconds.

AHI, Apnea-Hypopnea Index for Sleep Apnea:
Less than 5 events (apnea or hypopnea) per hour is considered normal.
5 or more events per hour is considered Mild sleep apnea
15+ considered Moderate
30+ considered Severe
(from T. S. Johnson MD, Sleep Apnea - The Phantom of the Night, page 211)

The AHI doesn’t tell the whole story. A person may have a low AHI but severe sleep apnea. The duration of events and degree of oxygen desaturation are also important.


A sleep study uses a pulse oximeter, a device with a red light that clips on your finger. It measures oxygen levels in your blood by noting the color; oxygenated blood is bright red, blood with hemoglobin desaturation is darker red. A pulse oximeter alone may detect severe sleep apnea, but is not reliable in less severe cases.

Get a copy of your sleep study report. You can refer to it from time to time as you manage your treatment. If you visit a specialist (sleep doctor, Ear/Nose/Throat doctor, pulmonologist, cardiologist, eye specialist, allergist, surgeon, dentist, etc.), give them a copy of your sleep study.

KNOW YOUR NUMBERS. Know your AHI, Apnea Hypopnea Index. This is a key number, like knowing your height, weight, blood pressure, or cholesterol level. Sleep apnea treatment (a dental device, pillar technique, CPAP machine) may differ depending on the severity of the sleep apnea.
Comprehensive Sleep Lab Orientation in Print
There are two chapters on sleep testing and understanding your report in the book Sleep Apnea – The Phantom of the Night by TS Johnson MD et al.

Short Sleep Lab Orientation Online Video
View a video and learn more at http://www.cpap.com/cpap-faq/Sleep-Study.html

Tips for Wearing a Mask for the First Time During the Sleep Study
Expect elaborate headgear, face straps, and stiff, bulky plastic nose pieces that make you look like an astronaut. While the sleep technician puts the mask on you, breathe through your mouth. Before you are hooked up to the CPAP machine, ask the technician to let you feel the airflow from the hose on your hand. It’s surprisingly breezy. It will feel much less breezy when felt through a mask. You won’t need it, but to make you more comfortable psychologically, ask the technician to show you how to quickly remove the mask and how to disconnect the mask from the hose or CPAP machine. The technician will show you how to call him or her during the night. While sitting up, spend a few moments “practice breathing” through the mask with CPAP turned on. It works! You can do it. You can even fall asleep while wearing it.

Other Laboratory Sleep Evaluations

For a brief description of the Maintenance of Wakefulness Test and Nap Study, see http://yoursleep.aasmnet.org/Studies.aspx

Alternatives to a Laboratory Sleep Study

In-home test though a physician. Some physicians and insurance companies suggest an in-home test. The patient wears various sensors and belts through the night. The results are monitored and reported. Sleep stages and brain waves cannot be measured as they are in a laboratory sleep study. One in-home process used by Kaiser measures apneas and hypopneas per hour, heart rate, respiratory effort, nasal-oral airflow, oxygen saturation using a pulse oximeter, body position, and snoring intensity and frequency. A simpler device is the Accutest SleepStrip, http://www.accutest.net/products/sleepstrip.php . If you explore these alternatives, discuss with your physician the need and ways to detect OSA (obstructive sleep apnea) vs. central apnea (brain not giving a signal to breathe) and mixed sleep apnea (combination of OSA and central), since treatment is different for the three types, as well as detecting other sleep disorders such as Restless Leg Syndrome. Also determine whether your insurance or Medicare will pay for subsequent treatment based on testing that is not the standard sleep study.

Diagnosis based on symptoms and perceived need may be an option for non-insured patients or patients with highly suspected obstructive sleep apnea (OSA) based on symptoms. Not Every Patient Needs to Go to the Sleep Lab is a thought-provoking Powerpoint presentation by a well respected board certified sleep doctor/pulmonologist, Dr. Barbara Phillips, at a meeting of the American Lung Association of the Central Coast in November 2004. Dr. Phillips is a professor of medicine at the University of Kentucky and is on the board of directors of the National Sleep Foundation. This approach would not detect central sleep apnea or mixed sleep apnea. Treatment differs depending on the diagnosis. If eligible, find out whether Medicare or Medicaid would pay for subsequent treatment without an overnight laboratory sleep study.


Humor by Mike Moran: Oct 13, 2005 A CPAP Failure and http://www.cpaptalk.com/viewtopic/t23827/Sermon-on-The-Mask-Humor.html and Dec 05, 2005 Twas Months After Sleep Study

Sources: Based on personal experience with obstructive sleep apnea.

Want more? See the peer coaching articles at http://smart-sleep-apnea.blogspot.com , http://www.cpap.com FAQ Learning Center, or search http://www.cpaptalk.com or post a message there.

Not written by healthcare professionals. The information and opinions offered are not intended or recommended as a substitute for professional medical advice.

© Mile High Sleeper, August 2006 - 2011. All rights reserved. You may make copies of this message and distribute in any media for free educational purposes, as long as you credit the author and include this copyright notice and the web address smart-sleep-apnea dot blogspot dot com

Tips for Newcomers to Sleep Apnea

For people with Obstructive Sleep Apnea and their healthcare professionals, peer coaching article #9, updated 21 November 2011

1. You’re in the driver’s seat. Take as much control in the process as possible so that you can make informed choices. The interventions are all for your benefit. Because you are the one being sleep tested or using the PAP (Positive Airway Pressure) machine, whether CPAP, AutoPAP or APAP, or BiPAP, you are the one who makes care and treatment successful. A well-meaning respiratory therapist who doesn’t have sleep apnea may suggest a certain mask, but he or she is not the one who needs to wear it every night. Don’t just passively follow, but actively partner and collaborate with your doctor, sleep lab technician, people at the DME (Durable Medical Equipment/Home Medical Equipment provider), and your insurance company. If your reasonable needs are not being met, be polite but assertive, persistent, and creative in pursuing what you need.

2. Whether in the sleep lab or at home with a PAP machine, no one is used to sleeping as a masked hose-head with a vacuum cleaner blowing air up their nose. Managing resistance and fear is a big part of the process. Direct your power of control inward, to manage your thoughts and feelings as well as outward, to manage treatment. Be kind and gentle with yourself, disciplined and determined when necessary. Humor helps. Get support from others. Related discussion thread: http://www.cpaptalk.com/viewtopic/t22566/Normal-to-be-angry-when-newly-diagnosed.html

Learn “The Seven Stages of CPAP and What Is Feeling Good?” in this blog, smart-sleep-apnea at blogspot dot com.

3. Take notes during and after visits with healthcare professionals. There is a lot of information to absorb, remember, and evaluate, with decisions to be made. Make a list of questions between visits to ask the next time you see your physician or respiratory therapist.

4. Control information flow to avoid being overwhelmed. Seek and absorb the information at your own pace so you can make informed choices.

First step: find out about sleep apnea, its health implications, and the sleep lab process and results. Accepting your diagnosis takes some emotional energy and wisdom. Learn that “I NEED TO DO THIS.”

Second step: find out about the various treatment options, based on the type and severity of your apnea. From a sleep study, you need to know your AHI, Apnea Hypopnea Index, or the number of “events” (apneas/no breath and hypopneas/shallow breath) you have per hour, and whether your sleep apnea is mild, moderate, or severe. For mild Obstructive Sleep Apnea (OSA), treatment may include a dental appliance or the pillar technique. For most sleep apnea from mild to severe, CPAP (or APAP or bilevel) may be the best treatment. If CPAP fails, these days surgery is rarely considered. Research long-term effects of surgery before making a decision. Talk with a sleep doctor about options. Internet websites have easily readable descriptions of the treatments and their effectiveness. The most usual option is a CPAP machine, or APAP or BiPAP. If you have OSA and your physician prescribes CPAP, explore the various types and brands of PAP machines through your physician, sleep center, Internet, books, and DME. Partner with your physician to select a fully data-capable or smart display machine, heated humidifier, mask. If your machine doesn’t have a display of AHI, you may buy machine software on your own.

Third step: When you are ready, get more details. If you are getting a machine, find out about the various types of interfaces or masks – nasal masks, nasal pillows, and full face masks. Some users rotate between a nasal mask and nasal pillows, using a full face mask when they have a stuffy nose from a cold. If you breathe through the mouth, a full face mask is probably the best choice. Internet sites from manufacturers, sellers, and user groups have a lot of information and opinions on masks and related equipment. Be discerning when reading user opinions. Most people try several masks over time before they find the one that works for them.

5. Failure is not an option. Determine to succeed. You have a choice of treating your sleep apnea or having a greater risk of high blood pressure, heart disease, stroke, car crashes due to falling asleep at the wheel, lack of mental clarity, lack of energy for relationships, and lack of zest for life. The initial obstacles to successful CPAP therapy are the user’s attitude and uncomfortable (occasionally unbearable) sleeping conditions due to unsuitable equipment. Gone is the illusion of a good night’s sleep. You may have temporary problems such as insomnia, bloating, and rainout (condensation in the hose). Don’t hastily give up on CPAP therapy, when instead you need to give up on a particular piece of equipment or solve a problem. For the first few weeks or months of therapy, the biggest event of each day may be the night. Train for it as you would for an athletic event. Manage your mindset. Manage caffeine, alcohol, drugs, diet, exercise. Get your nose working so you can breathe through it (or get a full face mask). Do your homework on equipment options and modifications. Through a combination of ongoing experimentation with better equipment and nightly practice, you can create acceptable (even comfortable) sleeping conditions and work your way toward good sleep again, truly good sleep. Learn that “I CAN DO THIS.”

6. Make friends with your mask. If you are so inclined, use common sense, mental imagery, visualization, prayer, or therapy to build a peaceful, harmonious, and beneficial relationship with your CPAP machine and equipment (masks, heated humidifier, hose or heated hose, bed pillow, machine software). The modern APAP machine with a heated humidifier, display or smart card with software is a marvelous invention. In contrast, for most people, masks are problematic, but there are many options to explore, and hopefully designers and manufacturers will improve masks in the future. Can you become friendly with your equipment? If you can’t, maybe it’s not you; maybe you have unfriendly equipment. Refit and modify it; experiment. Or replace it with equipment that is better suited to your well being.

7. Gather feedback on your progress. Consider keeping a nightly sleep log. A problem may go away one night but come back the next. With a diary or log, you can see, as well as feel, that you really are making progress over time in spite of frequent equipment struggles. If you get a machine with software tracking information, the data is enormously helpful for motivation and problem solving, for both you and your doctor. You will be well aware of problems. Remember to celebrate small victories.

8. Persist in having a positive, problem-solving attitude. Get creative ideas from an online CPAP community, local support group, and other users. Make improvements in your equipment and regimen. Give each change you make some time to work before trying another option. Learn to play the waiting game – waiting for appointments, insurance approval, equipment delivery, adapting to new equipment. Be patient, remembering it’s not always easy when you are sleep deprived. Stay with your therapy, however you need to modify it to make it work. Success is in your hands – and head.

Humor by Mike Moran: Dec 01, 2005 CPAP Slogans

Source: Written from personal experience. Not written by healthcare professionals. The information and opinions offered are not intended or recommended as a substitute for professional medical advice.
© Mile High Sleeper, August 2006 - 2011. All rights reserved. You may make copies of this message and distribute in any media for free educational purposes, as long as you credit the author and include this copyright notice and the web address smart-sleep-apnea dot blogspot dot com