Table of Contents with links within this blog

Updated December 2011

1 Sleeping with the Enemy

http://smart-sleep-apnea.blogspot.com/2011/12/are-you-sleeping-with-enemy.html

2 Evaluating Your Sleep, Denial and Awareness

http://smart-sleep-apnea.blogspot.com/2011/12/evaluating-your-sleep-denial-and.html

3 Sleep Study and Alternatives

http://smart-sleep-apnea.blogspot.com/2011/12/sleep-study-and-alternatives.html

4 Diagnosing Sleep Apnea without Insurance

http://smart-sleep-apnea.blogspot.com/2011/12/diagnosing-sleep-apnea-without.html

5 Social and Psychological Factors in Sleep Disorder Recovery

http://smart-sleep-apnea.blogspot.com/2011/12/social-and-psychological-factors-in.html

6 Resources for Learning about Sleep Apnea

http://smart-sleep-apnea.blogspot.com/2011/12/resources-for-learning-about-sleep.html

7 CPAP Adaptation Stages and Recovery

http://smart-sleep-apnea.blogspot.com/2011/12/cpap-adaptation-stages-and-recovery.html

8 Seven Stages of CPAP and What Is Feeling Good?

http://smart-sleep-apnea.blogspot.com/2011/12/seven-stages-and-what-is-feeling-good.html

9 Tips for Newcomers to Sleep Apnea

http://smart-sleep-apnea.blogspot.com/2011/12/tips-for-newcomers-to-sleep-apnea.html

10 Your CPAP Support Team

http://smart-sleep-apnea.blogspot.com/2011/12/your-cpap-support-team.html

11 Short List of My Best PAP Equipment

http://smart-sleep-apnea.blogspot.com/2011/12/short-list-of-my-best-pap-equipment.html

12 CPAP Machine Choices

http://smart-sleep-apnea.blogspot.com/2011/12/cpap-machine-choices.html

13 CPAP Humidifiers

http://smart-sleep-apnea.blogspot.com/2011/12/cpap-humidifiers.html

14 CPAP Mask Choices

http://smart-sleep-apnea.blogspot.com/2011/12/cpap-mask-choices.html

15 Solving CPAP Mask Problems (typo in title)

http://smart-sleep-apnea.blogspot.com/2011/12/soving-cpap-mask-problems.html

16 Solving Common CPAP Equipment Problems

http://smart-sleep-apnea.blogspot.com/2011/12/solving-common-cpap-equipment-problems.html

17 Checking Your CPAP Machine Settings – Basic Information

http://smart-sleep-apnea.blogspot.com/2011/12/checking-your-cpap-machine-settings.html

18 Changing Your CPAP Pressure Settings

http://smart-sleep-apnea.blogspot.com/2011/12/changing-your-cpap-pressure-settings.html

19 Everyday CPAP Safety

http://smart-sleep-apnea.blogspot.com/2011/12/everyday-cpap-safety.html

20 Preventing and Reporting Errors in Your Care

http://smart-sleep-apnea.blogspot.com/2011/12/preventing-and-reporting-errors-in-your.html

21 CPAP Equipment Cleaning and Replacement

http://smart-sleep-apnea.blogspot.com/2011/12/cpap-equipment-cleaning-and-replacement.html

22 Specific Health Conditions and OSA Recovery

http://smart-sleep-apnea.blogspot.com/2011/12/specific-health-conditions-and-osa.html

23 Mike Moran’s CPAP Humor Links

http://smart-sleep-apnea.blogspot.com/2011/12/mike-morans-cpap-humor-links.html

24 More CPAP Humor Links

http://smart-sleep-apnea.blogspot.com/2011/12/more-cpap-humor.html

25 Sleep-Related Web Sites

http://smart-sleep-apnea.blogspot.com/2011/12/more-sleep-related-web-sites.html

26 Diary of Two Hoseheads

http://smart-sleep-apnea.blogspot.com/2008/01/diary-of-two-hoseheads.html

27 AWAKE Group Workshop Design for CPAP Peer Coaching

http://smart-sleep-apnea.blogspot.com/2011/12/awake-group-workshop-design-for-cpap.html

Are You Sleeping with the Enemy?

For people with Obstructive Sleep Apnea and their healthcare professionals, peer coaching article #1, reviewed 21 November 2011

Are You Sleeping with the Enemy? by Scott Standage MD

(email: drbandage@yahoo.com), submitted by SleepGuy. Used with permission.

If an intruder tried to suffocate you with a pillow hundreds of times a night, you’d call the police. In the case of sleep apnea, the airway blocks off and breathing will stop for up to several minutes--but the victim has no idea it's even happening. According to Ralph Downey III, PhD, of the Sleep Disorders Center at Loma Linda University Medical Center in Loma Linda, California, “The body, in essence, is being assaulted by the damage done from intermittent lack of oxygen to the heart, brain and other important organ systems, and yet such an assault goes unreported. That is, patients who have these symptoms don't always have their sleep apnea corrected. Perhaps in the light of a metaphor such as the one of being assaulted by our own sleep disorder, people would take more care of their sleep. Their hearts will thank them.”

Truth be told, sleep apnea may well be the most significant, costly, easily treated, and least understood public health issue facing our nation. The most recent studies predict that between 50 and 60 million Americans are “at high risk” for having sleep apnea. And very few of them have the slightest idea what sleep apnea is, much less that it may be affecting their lives in profound ways.

The Basics Apnea is the medical term for “stopping breathing.” Sleep apnea is the temporary cessation of breathing during sleep, for intervals of 10 seconds up to minutes in length, depriving the body of oxygen. At some point the body arouses just enough to resume breathing and disrupt sleep, but usually not enough to awaken the individual. As a result, most people suffering from sleep apnea are not aware of their condition. In the most common type, obstructive sleep apnea (OSA), the airway blocks off when the tongue and/or other soft tissues in the throat relax and the individual simply stops breathing, sometimes for several minutes. This sequence can be repeated hundreds of times a night.

Apart from disrupting normal sleep patterns, sleep apnea wreaks havoc on the victim's body due to oxygen deprivation and physiological response patterns that occur during apnea events. There is no physiological signal stronger than oxygen deprivation to the brain. When blood oxygen levels are low, the body shunts blood from any and all organs, including the heart, to be sure the brain gets all available oxygen. On top of that, the sympathetic nervous system kicks in and releases a tremendous flood of stimulants and stress hormones, such as epinephrine (adrenaline) and cortisol, resulting in the well-known "fight or flight" response to danger.

Suppose somebody were to sneak up on you in the dark and lunge at you when you least expect it. Your heart races, the endocrine system instantly pumps out inordinately powerful stimulants. Sleep apnea victims are constantly confronted with a similar phenomenon and the accompanying red alert, each time their oxygen levels drop to a critical point. Another cruel twist happens when blood oxygen levels hover just above the critical desaturation level, getting just enough oxygen on board to avoid the arousal but not enough to provide the oxygenation that the body needs to stay healthy. The desaturation graph is remarkable for a very precipitous drop around the mid-to-upper 80% range for most people with sleep apnea.

Repetitive apneic events disrupt the normal physiological interactions between sleep and the cardiovascular system. Sleep fragmentation, with its accompanying increased sympathetic activation, triggers vascular endothelial dysfunction, increased oxidative stress, inflammation, increased platelet aggregability, metabolic dysregulation; in addition, it undoubtedly helps initiate and accelerate the progression of cardiac and vascular disease. Persuasive data implicate sleep apnea in the development of hypertension, and sleep apnea also contributes to cardiac ischemia, congestive heart failure, cardiac arrhythmias, and cerebrovascular disease and stroke.

At least if you’ve been attacked by a mugger you know to avoid ever going down that dark alley again. Sleep apnea, conversely, does not tip its hand. The victim’s conscious mind has virtually no recollection of the hundreds of assaults occurring during sleep every night.

It should not be surprising that common symptoms of sleep apnea include things like loud snoring and a gasping or snorting sound, high levels of daytime fatigue, irritability, depression, malaise, loss of productivity and work performance, extreme mental and physical exhaustion, loss of judgment, short-term memory dysfunction, and a number of other symptoms.

The Astounding Prevalence of Sleep Apnea in America The numbers are shocking. The most recent studies have shown that one in four adults in the United States (31% of all men and 21% of all women over 18) is “at high risk” for OSA, based on analysis of the National Sleep Foundation’s 2005 Sleep in America survey. Another study showed that one third of all people over 18 (who visit a primary care doctor) are at “high risk” for sleep apnea. Based on the 2000 Census, that means that between 50 and 60 million Americans likely suffer from sleep apnea. This is far higher that previous estimates that projected that between 10 and 18 million Americans have sleep apnea. Increasing awareness of sleep apnea and improved survey screening tools, along with an aging U.S. population, seem to be factors in the increase in OSA prevalence estimates. No longer should sleep apnea be thought of as an affliction of middle-aged, overweight men. The disorder is dependent on a number of factors (including, in particular, anatomy) and afflicts untold millions of otherwise young and fit women and men.

The Unacceptable Human and Economic Toll According to the National Commission on Sleep Disorders Research, 38,000 cardiovascular deaths a year in the United States are directly attributable to sleep apnea. On top of that, sleep apnea is associated with a large number of serious, co-morbid medical and psychological conditions, such as hypertension, abnormal heart rhythm, sleep deprivation, stroke, heart disease, diabetes, depression, memory loss, poor judgment, and change in personality. As a result, undiagnosed and untreated sleep apnea victims are significant consumers of healthcare services.

In Canada, sleep apnea victims were shown to consume 23 to 50% more medical services in the five years prior to diagnosis than control subjects, with hypertension and cardiovascular disease accounting for the majority of increased costs. A recent study from Israel showed that healthcare utilization was 1.7-fold higher by sleep apnea patients compared to the control group, with 25% of the sleep apnea patients who consumed the most resources accounting for 70% of the total healthcare expenditures. Other studies have demonstrated that successful sleep apnea treatment results in significant improvement in co-morbid conditions, including, specifically, cardiovascular disease, hypertension, diabetes, stroke, and depression.

Cardiovascular disease is the most significant killer in the United States, resulting in over 685,000 fatalities and $40.4 billion in healthcare costs annually. Hypertension healthcare costs in the United States are approximately $19 billion. While it is not known what percentage of all cardiovascular and hypertension healthcare costs is attributable to untreated sleep apnea, in light of the fact that between 50 and 65 million Americans are at high risk for the disease, it stands to reason that undiagnosed and untreated sleep apnea no doubt account for billions of healthcare dollars spent treating conditions that could be more effectively and far more economically treated as a sleep disorder. The human value in savings of physical pain and mental anguish associated with invasive procedures, surgeries, and chronic disease and death cannot be quantified.

Collateral Impacts Collateral impacts arising from 50 to 60 million clinically sleep-deprived people in the United States are certainly incalculable. One report focusing on highway safety impacts from sleep apnea concluded that more than 800,000 sleep apnea-related highway accidents occurred in 2000, resulting in 1,400 fatalities and costing nearly $16 billion. If the same analysis were performed today using the new, much higher sleep apnea prevalence rates, the highway safety impacts would probably be twofold higher. Because extreme daytime exhaustion is prevalent among OSA victims, sleep apnea-related losses due to reduced worker productivity, industrial accidents, clerical mistakes, and so forth would be almost impossible to estimate, but, given the numbers, would no doubt amount to the billions of dollars annually. On top of this, the personal quality of life impacts—depression, personality changes, lack of judgment, irritability, utter exhaustion—cannot possibly be measured in economic terms.

Simple, Economic Treatment The best news in sleep apnea is that it is a condition that is easily and economically treated. Continuous positive airway pressure (CPAP) therapy is the treatment of choice for obstructive sleep apnea and has been proven to be highly effective in treating sleep apnea and improving a number of co-morbid conditions. CPAP therapy consists of a ventilatory device that applies positive airway pressure at a constant, continuous pressure to help keep the airway open, allowing the patient to breathe normally during sleep. A number of other treatment options are also employed, such as surgery and dental appliances but questions remain as to the effectiveness of these treatment alternatives.

Where To Go from Here Perhaps the biggest challenge in addressing the sleep apnea health crisis is lack of public awareness (including many doctors). Just to put this into context, 13,658 Americans died from AIDS in 2003 while at least 38,000 died from cardiovascular disease related directly to sleep apnea. Yet while virtually everyone over 14 knows about AIDS, precious few of the 50 to 60 million Americans plagued by sleep apnea have any idea that a treatable sleep disorder is impacting every aspect of their lives. At the same time, a little awareness on the part of the patient or his or her doctor is all that it takes for treatment to start and, hopefully, for the suffering to end.

Unfortunately, a large number of doctors are still not very familiar with sleep apnea or its treatment. Primary care physicians are in an excellent position to screen people for sleep apnea, as one in every three adults they see, on average, will be “at high risk” for the condition. An excellent place to start (both for doctors and for individuals) is to fill out a one-page, ten-question survey called the “Berlin Questionnaire” that is widely available on the Internet http://www.pur-sleep.com/uploads/BerlinQuestionnaire.pdf . This questionnaire is simple and fast, and is highly predictive of sleep apnea—the positive predictive value of the survey for people scoring as “high risk” is 89%. Sleep apnea victims often have to work hard to convince their doctor (or insurance company) to refer them for a sleep study, so a "high risk" showing on the Berlin Questionnaire might be enough to convince them to move forward with further tests. If people are not satisfied with their medical care they should get a second opinion, preferably from a sleep disorder specialist. A number of overnight screening assessment tools are also available. A formal sleep study is necessary, however, to diagnose sleep apnea and obtain CPAP treatment.

Evaluating Your Sleep, Denial and Awareness

For people exploring sleep apnea and for their healthcare professionals, peer coaching article #2, updated 21 November 2011

The symptoms of sleep apnea (stopped or reduced breathing during sleep) can be very subtle and easily attributed to other factors. How can you tell what you do while you’re sleeping? It’s not unusual to be unaware of having sleep apnea, a nighttime respiratory disorder. You may think you are sleeping well. You may be in denial of the condition and unaware of its serious health risks. Your bed partner or family may be more aware of a potential problem than you are. Fifty percent or more of people with sleep-disordered breathing (SBD) remain undiagnosed. (Carl E Hunt MD p. xi in Johnson’s Sleep Apnea – The Phantom of the Night).

The Boiled Frog Analogy. Maybe you’ve heard this story. If you put a healthy frog into a pot of hot water, it will quickly jump out. If you put a frog into a pot of lukewarm water, and very gradually increase the temperature, it will stay in the pot until boiled. In the hot water, the frog noticed instant discomfort and danger and took action. In the tepid water, it was lulled into complacency until unaware or unable to take action. How does this translate to sleep apnea? Have you unconsciously adapted to fatigue and eventually daytime sleepiness because its progression was so long and gradual? Have you found other reasons for fatigue, while making the best of circumstances? Are those reasons valid? You can find out by consulting a physician, taking informal sleep quizzes and, if indicated, getting a sleep study in a sleep lab. When you find the real reason for your fatigue, you can crawl out of the pot to change, improve, or reverse the condition.

Untreated sleep apnea can lead to high blood pressure, stroke, heart attack, congestive heart failure, cardiac arrhythmia, depression. Other risks are driver fatigue, poor judgment, poor memory, and sleepiness leading to car crashes, wrongful death and injury.

Possible Symptoms of Sleep Apnea

·        loud and frequent snoring (in most people, but not in everyone)

·        periods of not breathing (apnea) during sleep, snorting, gasping, or choking during sleep

·        need to urinate at night

·        awakening tired in the morning, morning headaches, daytime or evening fatigue or lethargy

·        daytime or evening sleepiness when sitting or inactive, drowsy driving or falling asleep while driving

·        performing actions automatically or by rote, limited attention, memory loss

·        poor judgment, personality changes

·        weight gain, early onset of high blood pressure, severe leg swelling

·        especially in children, hyperactive behavior.

Possible risk factors:

·        overweight with a body mass index (BMI) of 25 or more

·        neck size for a man of 17 inches or more or for a woman of 16 inches or more

·        male gender, being a menopausal or postmenopausal woman

·        family history of sleep apnea, large adenoids or large tongue, short lower jaw which causes the tongue to position itself further back in the throat

·        smoking and use of alcohol or sedatives.

Sources: adapted from the journal Sleep, National Institutes of Health, and James C. O’Brien MD.

More possible hints of sleep apnea:

·        COPD (chronic obstructive pulmonary disease), asthma

·        heart abnormalities, stroke

·        high blood pressure that doesn’t respond to medication

·        acid reflux or GERD

·        diabetes

·        deviated septum (cartilage separating the nostrils going off midline)

·        bruxism (teeth grinding)

·        adult bed wetting

·        irritability, mood changes, anxiety, depression

·        procrastination, difficulty acting on plans or finishing projects, diminished work performance

·        social withdrawal, neglected relationships

·        less interest in sex, sexual dysfunction

·        persistent recurring dreams of struggle and failure

·        the ability to fall asleep two or three hours after getting up in the morning, and/or very long naps in the afternoon, and/or sleeping nine or more hours a night

Assessment Quizzes

If you suspect a sleep problem, take some of these quizzes. They are designed to build awareness and create dialog with your doctor, not to diagnose. Discuss the quiz results and your symptoms with your primary care physician, or a sleep doctor, pulmonologist (breathing specialist), cardiologist, ENT (Ear/Nose/Throat) doctor, or other specialist. If indicated by symptoms, the doctor may suggest a sleep study to rule out sleep apnea or other diagnostic procedures.

In print, an excellent quiz to help detect sleep apnea is in the appendix of Sleep Apnea – The Phantom of the Night , a book by T. Scott Johnson MD, William A. Broughton MD, Jerry Halberstadt, a patient. An online version is at

http://www.healthyresources.com/sleep/apnea/phantom/orders/quiz.html

Epworth Sleepiness Scale and Scores widely used by sleep doctors

http://www.stanford.edu/~dement/epworth.html

American Academy of Family Physicians, Berlin Questionnaire, http://www.swclab.com/images/PDFS/Berlin-Questionnaire.pdf

Online sleep evaluation

http://yoursleep.aasmnet.org/SleepEval.aspx

Early Warning from an Overnight Recording Pulse Oximeter

When you have a routine visit to your physician, along with taking your temperature, the nurse may use a pulse oximeter on your finger tip to measure the oxygen in your blood. The device measures oxygen levels in your blood by noting the color. Oxygenated blood is bright red, blood with hemoglobin desaturation is darker red. It’s painless and noninvasive. Can you get access to not just an ordinary pulse ox, but one that records oxygen levels over time, from your doctor, a friend, rental, or purchase? It’s easy to wear a recording pulse ox overnight in the comfort of your own bed. If the reading in the morning shows a drop in oxygen level beyond a certain percentage, consult a physician, showing him/her the record. This may be an early warning that you have sleep apnea, since most people don’t notice any symptoms. A pulse oximeter alone may detect severe sleep apnea, but is not reliable in less severe cases.

Sleep Study Information

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 – by checking airflow in your nose or mouth, snoring, and the effort your chest makes to breathe in various positions and in different stages of sleep. A lab study will 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 $4,000 or more.

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.

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.

KNOW YOUR NUMBERS. Know your AHI, Apnea Hypopnea Index. This is a key number resulting from the sleep study, 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. Three simple definitions are useful:

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.

Sources: Based on personal experience with obstructive sleep apnea and gleaned from the collective wisdom of cpaptalk.com contributors.

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

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

Diagnosing Sleep Apnea without Insurance

For people with Obstructive Sleep Apnea and their healthcare professionals, peer coaching article #4, updated 21 November 2011

These suggestions are written for people with a low income who don’t have healthcare insurance (or who have extremely high deductibles), and who are not eligible for Medicare or Medicaid.

Only a doctor can make a diagnosis. First, do your homework about sleep apnea. Second, find a doctor who is informed about sleep disorders.

1. Realize that if you do have sleep apnea, your judgment may be somewhat impaired due to the toll that oxygen deprivation takes on your brain, energy levels, life perspective, and initiative. Consider asking a family member or friend to help you take the steps below, especially if you are fatigued, confused, or depressed.

2. Become informed about sleep apnea. If you don’t have a computer, use a friend’s computer or library computer. Read about the consequences of untreated sleep apnea in the article “Are You Sleeping with the Enemy?” at smart-sleep-apnea dot blogspot dot com. Read “Evaluating Your Sleep” at the same web site.

3. Take online quizzes and print the quizzes and results for your doctor. The Berlin Questionnaire and Epworth Sleepiness Scale have the most credibility with doctors. Find the Berlin Questionnaire at http://www.swclab.com/images/PDFS/Berlin-Questionnaire.pdf  Find the Epworth Scale at http://www.stanford.edu/~dement/epworth.html  An excellent quiz from the book Sleep Apnea – The Phantom of the Night lists symptoms at http://www.healthyresources.com/sleep/apnea/phantom/orders/quiz.html Do not rely on these quizzes for a diagnosis. They are designed to raise awareness (yours and your doctor’s), not to diagnose.

4. If your energy levels, behaviors, symptoms, and quiz results raise a concern that you may have sleep apnea, realize that you need diagnosis. It may seem difficult or impossible to pay for a sleep study test and subsequent treatment. However, if you have untreated sleep apnea and it leads to heart disease, stroke, diabetes, a car wreck or some other serious condition affecting your work, it will be far more difficult to pay for treatment of that resulting condition. “An ounce of prevention is worth a pound of cure.” An upfront investment in seeing a doctor could save you untold costs of a more serious disease. A doctor may be able to prescribe a CPAP machine without a hospital lab sleep study. An overnight sleep study in a hospital can cost $1500 and up. If diagnosed, a low-end CPAP machine for treatment costs around $300 bought new online.

5. Become informed about sleep tests by reading “Sleep Study Tests” at smart-sleep-apnea dot blogspot dot com.  See the sections about these important options: an overnight recording pulse oximeter, an at-home test, a presentation for doctors, Not Every Patient Needs to Go to the Sleep Lab, and a split-night study.

6. Find a doctor. If you have a regular doctor or clinic, are they actively aware of sleep disorders and their consequences? An option may be a sleep doctor, a doctor who specializes in sleep disorders. Here are three ways to find one. Phone a local hospital sleep lab, and ask if they can suggest a sleep doctor. Or find local services at http://www.cpaptalk.com/sleep-apnea-services-locator.php  Or find a sleep doctor through the American Board of Sleep Medicine.

7. Show the doctor your quiz results and discuss your symptoms. Explain your lack of insurance and financial circumstances and discuss options. Be aware that private healthcare insurance and Medicare may require a sleep study before paying for CPAP equipment. If an overnight sleep study seems unaffordable, does the doctor ever use at-home screening? Some automatic CPAP machines with a display or smart card and software can be used for a split night study and titration (finding your CPAP pressure setting) at home. Does the doctor ever use an auto PAP for these purposes? Read these articles below and ask your doctor’s opinion:

A. 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.

B.  Nonattended home automated continuous positive airway pressure titration: Comparison with polysomnography http://www.sleepsolutions.com/clinical_library/Unattended_auto-CPAP.pdf Quote: Nasal APAP titration in this study correctly identified residual apnea equivalent to the use of PSG. This correct identification allows the physician to accurately access the efficacy of treatment.

8. If you and your doctor decide on a sleep study or CPAP machine, get costs upfront. A doctor’s prescription is necessary for purchase of a CPAP machine. Internet CPAP sellers such as www.cpap.com are usually able to sell new machines at a much lower price than local Durable Medical Equipment suppliers, and provide advice as well. For information on CPAP machines, see http://www.cpap.com/cpap-machines.php

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

Social and Psychological Factors in Sleep Disorder Recovery

For people with Obstructive Sleep Apnea and their healthcare professionals, peer coaching article #5, updated 21 November 2011

“I realized that I had a handicap rather than a moral defect. Finally, I could stop criticizing myself for not meeting social and personal standards of behavior.” Sleep apnea patient Jerry Halberstadt, Sleep Apnea – The Phantom of the Night, p. 154

Just as we’re all different in our physical conditions, we’re all unique in our psychological nature and approach to life. Listed below are a few personal issues related to sleep disordered breathing (SDB) and CPAP treatment that can come up, not even including equipment issues. If you have a family member or friend who is not very supportive of your condition and CPAP therapy, perhaps discussing some of these items will increase their awareness and understanding.

“Have I accepted that I have a serious medical condition, or am I still in some stage of denial? What emotional impact has this diagnosis had on me? How am I dealing with it? Am I making the best decisions in this weary and sleep-impaired condition? How good is my judgment? If I haven’t denied having sleep apnea, have I adopted the harmful and false belief that I can’t get used to CPAP?

This is the first time I’ve had a serious medical condition. Is it really life-threatening? It brings up issues of vulnerability, infirmity, aging, and mortality that I haven’t experienced before. How do I feel about that? Or, now I have this condition on top of other serious conditions. How do they affect each other? How do I deal with them all?

Why don’t more people understand sleep apnea? Why did my doctors not diagnose my sleep apnea for so many years? Did they misdiagnose and mistreat my other health problems when they were really sleep apnea? Did undiagnosed sleep apnea cause my other health problems? How do I feel about that?

Is untreated sleep apnea an affliction, a chronic disability, a handicap? If it’s effectively treated, is it still a handicap or impairment? Will I ever feel as good as before? How does this affect my image and self-concept? What will others think of me at home, at work, in the world?

How difficult is the therapy? How do I face my fears? Can I succeed? Can I do this long term; do I want to? What kind of support do I need and can I get?

I don’t like being dependent or an addict. How do I deal with being tethered to a machine every night for the rest of my life? How do I deal with being dependent upon a machine for my health and well being?

How does this affect my spouse, family, friends, co-workers? How can they deal with these changes? How do they support me? What blocks are other people putting up? What blocks am I putting up? How well do I support myself? How do I get around these blocks?

How does using CPAP equipment at night affect the comfort of my bed partner and sexual relations or dating? My libido is still low. Will that improve? Or, my libido is much better now that I’m on CPAP. Either way, it’s affecting my relationship.

Before now, I haven’t needed to deal with the healthcare system very much - doctors, specialists, insurance, hospital sleep labs, local or online Durable Medical Equipment (DME) or Home Medical Equipment providers. Who does what? How good are they? How do they interact? How do I make it all work for me?

Where is the best place to get equipment (CPAP machine, heated humidifier, masks, software, etc.), at the doctor or sleep lab acting as a DME, at a local large national DME or local small DME or online DME, or some combination? Which DMEs does my insurance authorize? What does the DME charge and what percentage does insurance pay; what are the deductibles? Where can I get the best value, prices, and service? Is it sometimes more cost effective to pay out-of-pocket and shop online instead of using insurance and the local DME with its pricing and insurance deductibles? If I shop online, what about service; can I still get mask trials and fittings somewhere locally?

What are the costs that I need to pay on my own? What can I afford? Are costs mainly start-up, and how much is ongoing? What equipment is worth spending more on? Are there places where it’s okay to be economical, or will that hinder effective treatment in the long term? What’s the overall effect on my health and quality of life, the cost-benefit ratio?

What do I do when part of the healthcare system doesn’t work? What do I do when I run into inadequate treatment or lack of integrity? Why do I need to deal with incompetent people or dysfunctional organizations when I’m already challenged enough by my condition and with making the therapy work for me? Is there hope for large national Durable Medical Equipment providers’ improvement or is it hopeless trying to deal with them? Is it worth the emotional distress to deal with them? What are the issues? What is my moral obligation to bring attention to the situation so other people aren’t harmed by lack of information, misinformation, incompetence, or unethical treatment of patients and questionable business practices? Where and how can I help and be effective?

I still don’t feel as good as I used to feel before. The results vary a lot. Sometimes I’m up, sometimes I’m down. I haven’t achieved stability or consistency. I still get tired or depressed. I have more mental energy to accomplish things, but not the physical energy. Or, I feel a lot more physical energy but don’t know what to do with it anymore. I feel new levels of energy but don’t know how to handle it, how to integrate it into my daily life.

Have I achieved success with my CPAP therapy – is this as good as it gets? Or will my standard of success change, will the bar be raised, after I’ve been on CPAP for a while? How long does it take to feel optimal? What is optimal?

Was it me or was it sleep apnea? What past actions, performance, and psychological state was the impairment of sleep apnea, and how much was me or my character? Who was I? Does it matter? Even more important, now that my energy is returning, who am I now, at this age, with this condition? Do I need to reinvent myself? How?

What things were hidden from me because of fatigue and lack of attention? I’ve been neglecting things for years. What things have been harmed or have self-destructed because I didn’t have the energy to deal with them? What do I do about them now? What do I do about my health? Weight? Fitness? Relationships? Family? Friends? Work? Finances? Dreams and goals? Fun parts of my life? What have been the costs of this unknown, untreated ailment? What losses do I need to mourn? How do I get my life back? How do I play catch-up? What is possible? How long will it take?”

These are important life issues about loss, change, and rebuilding. Dr. Elizabeth Kubler-Ross studied death and dying and came up with five stages that apply to any loss, not just death. The stages aren’t always sequential; they overlap or people go backward as well as forward. The point is to not get permanently stuck in one stage, but to eventually reach the acceptance stage. It’s natural to be going through these stages in dealing with the many physical, psychological, quality-of-life effects of Obstructive Sleep Apnea (OSA); not only what happened to your body and mind while untreated, but to other aspects of your life:

Denial. Isolation. “This is not happening/did not happen to me.”

Anger.  Blame. “How dare they do this to me!” “How did I let this happen?”

Bargaining. Unrealistic attempts to fix. “If I just do this, that will happen.”

Depression. Regret. “I’m so sad about what happened to (some aspect of my life). ” “I can’t bear to face going through this adjustment, or putting my family through this.”

Acceptance. Gaining a realistic perspective. This doesn’t mean you like it, but you do accept that it’s happening or that it did happen. “I’m ready to face it. I don’t want to struggle or deny it anymore.”

Maybe the next interim stage is mourning or grieving the deterioration or death of parts of your life, before you move on to adaptation or rebuilding.

Psychologist William Bridges in The Way of Transition describes three sequential stages of psychological transition during any change, which can be applied to adapting to CPAP and the consequences of OSA. Getting stuck in the first two stages is a block to successful transition. See http://www.wmbridges.com/

Endings or Saying Goodbye. Letting go of the way things were. Maybe mourning.

Chaos or Wilderness Zone or Shifting into Neutral. Uncertainty, confusion. Not knowing what’s what. There is lots of this in getting used to CPAP therapy.

New Beginnings or Moving Forward. Behaving in a new way.

If you think you might benefit from it, seek understanding help from a psychiatrist, psychologist, therapist, religious or spiritual leader, or healer. Patiently rebuild your new life. Take heart that you now are gaining energy to find out who you are and who you want to become. Successful CPAP users seem to be practical and pragmatic. The CPAP therapy proves itself through results, health, well being, improved quality-of-life. Their gratitude for the results of CPAP treatment overcomes their concerns about dependency on the machine.

Look for recent additions to these discussion threads on http://www.cpaptalk.com :

Singles and OSA (Obstructive Sleep Apnea):

http://www.cpaptalk.com/viewtopic/t16860/Singles-XPAP-obvious-at-night.html

http://www.cpaptalk.com/viewtopic.php?t=19913&postdays=0&postorder=asc&start=0

Emotions and OSA:

http://www.cpaptalk.com/viewtopic/t25336/Sleep-Deprivation-and-your-quotRun-Amokquot-Emotions.html

Insomnia, Anxiety, Trauma, PTSD, Nightmares, Sleeping Pills

http://sleeptreatment.com/ and the book Sound Sleep, Sound Mind by Barry Krakow, MD

http://www.cpaptalk.com/viewtopic.php?t=20756&postdays=0&postorder=asc&start=0

Depression and OSA:

http://www.cpaptalk.com/viewtopic/t20790/Initially-misdiagnosed.html

http://www.cpaptalk.com/viewtopic/t25139/CPAP-for-Sleep-Apnea-Improves-Depression.html

http://www.cpaptalk.com/viewtopic.php?t=22015&postdays=0&postorder=asc&start=0

http://www.cpaptalk.com/viewtopic.php?t=10601&postdays=0&postorder=asc&start=0

http://www.cpaptalk.com/viewtopic/t18172/Depression-and-CPAP.html

http://www.cpaptalk.com/viewtopic.php?t=5156

http://www.cpaptalk.com/viewtopic.php?t=6348

http://www.cpaptalk.com/viewtopic.php?t=10601

Escaping from the sick role and OSA:

http://www.cpaptalk.com/viewtopic/t25371/Escaping-from-the-quotsick-rolequot.html

Humor by Mike Moran: Aug 01, 2006 CPAP Stand Up (Humor)

Sources: Based on personal experience with obstructive sleep apnea and gleaned from the collective wisdom of cpaptalk.com contributors.

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