Sleep Apnea

Sleep Symptoms

Evaluating Your Sleep - Symptoms by Mile High Sleeper

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 probably 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). Other estimates are that only 5% of people with SBD have been diagnosed. Most physicians do not routinely screen for sleep apnea, and may treat resulting conditions such as high blood pressure or depression, without discovering the root cause - SBD. Most people are unaware of the symptoms and risk factors. What is needed is early detection before heart damage or falling asleep at the wheel.

Untreated sleep apnea can lead to high blood pressure, stroke, heart attack, congestive heart failure, cardiac arrhythmia, depression, glaucoma, obesity, diabetes, and a host of other medical problems. Other risks are driver fatigue, poor judgment, poor memory, and sleepiness leading to car crashes, wrongful death and injury.

The Most Important Symptoms of Sleep Apnea

• loud and frequent snoring (often but not always)

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

• need to urinate during the night (nocturia) See http://www.nocturiacures.com/

• high blood pressure

• morning headaches

• awakening tired in the morning, 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, severe leg swelling

• especially in children, hyperactive behavior.

National Institute of Health sleep apnea links http://www.nlm.nih.gov/medlineplus/sleepapnea.html#cat5

Possible Risk Factors

• decreased size of the airways in the throat, nose, or mouth due to anatomy or allergies. 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

• 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, or being a menopausal or postmenopausal woman. Both genders and all ages from infancy onward may have this condition.

• 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 Indicators 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)

• insomnia

• 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 long naps in the afternoon, and/or sleeping nine or more hours a night

Assessment Quizzes

If you suspect a sleep problem, take at the quiz listed below. Quizzes 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.

A very comprehensive but easy quiz looks at a wide variety of symptoms to help detect sleep apnea 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 of this excellent quiz is at http://www.healthyresources.com/sleep/apnea/phantom/orders/quiz.html

Additional Sleep Apnea Assessment Questionnaires can be found here.

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.

Diagnosing Sleep Apnea

Who can Diagnose Sleep Apnea?

Sleep doctor, Ear/Nose/Throat doctor, pulmonologist, cardiologist, eye specialist, allergist, surgeon, dentist, other specialist

Visiting the Sleep Lab

Sleep Study Options

by Mile High Sleeper

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 – 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 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 between $1,500 and $4,000.

Option 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.

Option 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: 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.

Option 3 A 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 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.

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.

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 auto-titration settings instead of sleep lab titration. 2) prescription 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 /home care provider, DME). None of this is extraordinary; it’s equipment and a feedback process that may be selected by the doctor and patient regardless of type of sleep study.

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.

What to Expect during a Sleep Study

Three definitions are useful for the sleep study.

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

A sleep study uses a pulse oximeter, a device with a red light that clips on your finger. It measure oxygen levels in your blood by noting the color; oxygenated blood is bright red, blood with hemoglobin desaturation is darker red.

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 DVD or Online Video

“Introduction to the Sleep Lab” Order from https://www.cpap.com/productpage/cpaptalk.com-introduction-to-the-sleep-lab.html Allow time for delivery or view online at http://www.cpaptalk.com/cpaptalk-cpap-video-movie.php?videos=video&VGID=58

Tips for Wearing a Mask and Using CPAP for the First Time

• 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.

Making the System Work for You

Getting into a Sleep Specialist/Sleep Lab Quickly

author unknown

This might seem like a no-brainer, but I'm going to mention this anyway just in case someone out there needs this info.

Anyone who has been into see a sleep specialist / neurologist as a new patient and then has booked a night at a sleep lab knows all too well how even in first rate medical cities (ie. Boston; Philly; Cleveland) it can easily take 1-3 months to get an appointment with a good Neurologist / Sleep Specialist. And then you're at the back of the line again to get into a sleep lab. AND THEN you're at the back of the line AGAIN to get back into see your Neurologist for the results of the sleep study. And if your results are inconclusive as they often are, add another 1-3 months for a repeat night at a sleep lab etc etc. When you're suffering from Sleep Apnea, nothing is more painfull than knowing it might take 6-8 months to finally be treated for the disorder.

So here are my tactics for getting into Sleep Specialist, Sleep Lab, and most importantly getting treatment ASAP or well within 6-12 weeks.

1. After you book your first appointment with your Neurologist / Sleep Specialist, call the scheduling desk and quickly convey that you are available on short notice if anyone else should cancel their appointment. If they say they have a long list, then pull out the "friendliness card" and make sure you're well known to the office staff.

2. After your first night at the sleep lab is booked, get on the phone to the sleep lab and do the exact same thing. Sleep Labs bill $1,000-$4,000/night so they are always eager to book empty beds, and people cancel their sleep lab nights left and right.

3. After your night in the sleep lab, you have no choice but to wait for your results to be compiled and sent to your neurologist. But once you\'re able to get into see your Neurologist for follow up, get on the phone and request that the office call you for cancelled appointments.

Hope this helps! I've been into 5 sleep studies and this always works for me.

Suggested Specific CPAP Equipment Rx/Scripts

by CPAPtalk member Slinky

(Editor's note: a doctor's prescription is required for a PAP machine and mask whether through a local DME or online. Online, a generic CPAP prescription will work for either a CPAP or APAP. At a local DME, a prescription specific for APAP will probably be required. See prescription advice and requirements at https://www.cpap.com/cpap-faq/Prescriptions.html#FGID-130 )

If your equipment order (Rx/script) will be for "just" a straight CPAP and not one of the more sophisticated bi-levels (Bi-PAP) or SV, etc. most doctors write a fairly genetic script and then most DMEs will take advantage and provide you with a bare-bones CPAP.

I would suggest that you ask your doctor to write a very explicit equipment order so that you get EXACTLY what you want and really need. The following are some suggested orders (not that I am recommending one machine over the other, just to give you and your doctor an idea).

You will notice the similarities to each suggestion.

1] Exact brand and model of machine

2] Scripted pressure (the autoPAPs have a pressure range rather than a set pressure)

3] Scripted amount for lower pressure at exhalation

4] Starts w/4 cms of pressure and ramps up to your set pressure after you get to sleep

5] Allows you to access your nightly data via the LCD screen

6] While the integrated humidifiers are most convenient for travel and take up less space on your nightstand, in really dry situations sometimes they can't provide as much humidity as you might need or want. For many the integrated humidifiers are more than satisfactory.

7] This ensures that you can try several masks, including a Full Face mask (sometimes they insist on a script specifiying full face if the script just says mask, or will only provide the exact mask mentioned in the equipment order).

Sample 1 1] Respironics REMstar M Series Pro w/C-Flex (w/heated humidifer if you prefer)

2] Pressure ---- cms (whatever your pressure is)

3] C-flex setting 3 (or whatever your doctor suggests)

4] Ramp off (unless you prefer it on)

5] Show AHI/Leak feature On

6] Fisher & Paykel HC 150 heated humidifier (unless you prefer the integrated heated humidifer. If so just add "w/heated humidifier to the REMstar Pro"

7] Nasal mask, Full Face mask, or Nasal Pillows mask of patient's choice.

Sample 2 1] Resmed S8 Elite w/EPR (w/heated humidifer if you prefer)

2] Pressure ---- cms (whatever your pressure is)

3] EPR setting 3 (or whatever your doctor suggests)

4] Ramp off (unless you prefer it on)

5] Efficacy & Usage Data access

6] Fisher & Paykel HC 150 heated humidifier (unless you prefer the integrated heated humidifer. If so just add "w/heated humidifier to the Resmed S8 Elite)

7] Nasal mask, Full Face mask, or Nasal Pillows mask of patient's choice.

Sample 3 1] Respironics REMstar M Series Auto w/A-Flex (w/heated humidifer if you prefer)

2a] Minimum pressure (whatever your doctor has determined)

2b] Maximum pressure (whatever your doctor has determined)

3] A-Flex setting 3 (or whatever your doctor suggests)

4] Ramp off (unless you prefer it on)

5] Show AHI/Leak feature On

6] Fisher & Paykel HC 150 heated humidifier (unless you prefer the integrated heated humidifer. If so just add "w/heated humidifier to the REMstar Auto w/A-Flex"

7] Nasal mask, Full Face mask, or Nasal Pillows mask of patient's choice.

Sample 4 1] ResMed S8 AutoSet Vantage (w/heated humidifer if you prefer)

2a] Minimum pressure (whatever your doctor has determined)

2b] Maximum pressure (whatever your doctor has determined)

3] EPR setting 3 (or whatever your doctor suggests)

4] Ramp off (unless you prefer it on)

5] Efficacy & Usage Data access

6] Fisher & Paykel HC 150 heated humidifier (unless you prefer the integrated heated humidifer. If so just add "w/heated humidifier to the REMstar Auto w/A-Flex"

7] Nasal mask, Full Face mask, or Nasal Pillows mask of patient's choice.

To the best of my knowledge the only other fully data capable CPAPs (as of January 2008) are the Puritan Bennet GoodKnight 420E autoPAP and one other Puritan Bennet GoodKnight straight CPAP. I'm not sure of the correct model. Nor do I know the specifics for those Puritan Bennet's or I would have included them. Those who have the 420E really like them so hopefully further information can be included by someone who knows the Puritan Bennet devices.

Glossary for PSG (Sleep Study) Terms

The PSG Glossary is the first section of the CPAP Definitions page.

Get a copy of your sleep study report. You can refer to it from time to time as you learn more about 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.

Other Laboratory Sleep Evaluations

For a brief description of the Maintenance of Wakefulness Test and Nap Study, see http://www.sleepeducation.com/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, http://www.sleepdata.com/homecare.htm, 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. Simpler devices are the SLP Sleep Strip, http://www.slp-med.com/SleepStripTech.htm and 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.

Inexpensive screening for obstructive sleep apnea for the uninsured, for those who can’t afford insurance co-pays for a sleep study, or for those who want screening before a sleep study: https://www.cpap.com/productpage/slp-sleep-strip-at-home-sleep-study.html

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, http://www.alaccoast.org/pdf/Phillips_0830.pdf 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.

Relevant CPAPtalk Posts

Symptom Posts

Is it you or sleep apnea? http://www.cpaptalk.com/viewtopic/t17785/I-am-not-sure-everyone-understands.html?sid=2226cb049bfe94a360773a79e7d9ac78

Awareness for doctors and patients http://www.cpaptalk.com/viewtopic/t25205/Waking-Up-to-the-Problem-of-OSA--Improved-Recognition.html

What took you so long to seek diagnosis http://www.cpaptalk.com/viewtopic/t22134/What-took-you-so-long.html

What led to diagnosis http://www.cpaptalk.com/viewtopic/t23161/What-led-you-to-your-diagnosis-of-apnea.html

All ages http://www.cpaptalk.com/viewtopic/t27149/Can-young-people-have-Sleep-Apnea.html

Sleep apnea symptoms http://www.sleepdisordersguide.com/sleep-apnea-symptoms.html

More consequences, scroll down for the post from neversleeps: http://www.cpaptalk.com/viewtopic.php?t=16134&postdays=0&postorder=asc&start=15

Non-snorers with sleep apnea http://www.cpaptalk.com/viewtopic/t13698/Any-non-snorers-with-obstructive-sleep-apnea.html

Sleep apnea but not tired http://www.cpaptalk.com/viewtopic/t24108/I-have-severe-sleep-apnea-but-Im-not-tired-anyone-else.html

Weird symptoms http://www.cpaptalk.com/viewtopic/t24642/so-what-was-you-wierd-not-listed-symptom.html

How long have you had sleep apnea http://www.cpaptalk.com/viewtopic.php?t=21675&postdays=0&postorder=asc&start=

How SA affects life and health, scroll down for the post by countrygent http://www.cpaptalk.com/viewtopic/t26485/Well-Here-Goes.html

Dad refuses to see doctor http://www.cpaptalk.com/viewtopic.php?t=15831&postdays=0&postorder=asc&start=0

Trucker headed to court http://www.cpaptalk.com/viewtopic.php?t=16490&postdays=0&postorder=asc&start=0

Lucky to be treated http://www.cpaptalk.com/viewtopic/t16484/Im-SOOOOO-Lucky.html

See the peer coaching articles at http://smart-sleep-apnea.blogspot.com on Sleep Study Tests, Introduction to Sleep Apnea, More Sleep-Related Web Sites, and CPAP Machine Choices.

Sleep Lab Posts

Discussion threads:

http://www.cpaptalk.com/viewtopic/t14035/Cheap-Sleep-Apnea-Screening-Diagnosis-and-Auto-CPAP-Rx.html

http://www.cpaptalk.com/viewtopic/t14578/At-Home-Obstructive-Sleep-Apnea-Screener-Now-Available.html

Comments from a SleepStrip engineer: http://www.cpaptalk.com/viewtopic.php?t=14035&postdays=0&postorder=asc&start=15=Sleep Symptoms=