Prevalence of "Moderate-to-Severe OSA" in the 40-85-Yrs. General Population

Arlene1963 wrote: ↑

Wed Jan 30, 2019 2:54 pm

. . . linked to it several times on this forum . . .

I should remember it, then.

Keep an eye on me, Arlene1963, if I start repeating too much. It takes a community to keep me from getting caught in a loop.

Or maybe we can all take turns linking to it. Then we can all act surprised each time. Deal?

Deal! Except I might forget.

jnk... wrote: ↑

Wed Jan 30, 2019 1:56 pm

CG, had you seen that study? I don't remember ever seeing it.

But maybe my memory isn't what it once was.

Although I'm not sure how I can judge my memory based solely on my memory of my memory.

Don't try to drag me into your bad memories.

jnk... wrote: ↑

Wed Jan 30, 2019 12:26 pm

And some with that high of an AHI/RDI during sleep do not consider themselves symptomatic, would never fill out a sleepiness-scale test reporting sleepiness, and would never receive an OSA diagnosis. You or your doctor or someone somewhere has to think you have a sleep problem before you get tested for one, after all.

Well here's an interesting little tidbit. If you take those HypnoLaus patients and include only those with Epworth > 10, then the percentage of males is only 11.5 and females 4.8. Consequently, unless you test EVERYBODY you're (1) never going to find the great majority of HypnoLausPeople because not only do they think they're not sleepy, they are objectively "not sleepy", and (2) even if you find them, your compliance rate with CPAP would be less than zero because you're trying to treat something that isn't there.

And if you look at oxygen desaturation, HypnoLaus males using the 3% rule have an ODI of 14.4, but if you use the 4% rule the ODI is only 6.4. Is that clinically significant? And don't forget, once you're old, mortality from OSA drops, and 40% of the men in HL were >60.

So this is an impressive study, but what can you really do with it? Perhaps change criteria for initiating therapy?

Morbius!!!

Keep me honest. I need it.

As a layman, I consider Epworth subjective by its very nature. It's just a fancy way of asking a patient, in detail, "Are you sleepy?" from my point of view. If I could travel back in time, I would fill out my Epworth differently; I had no idea how sleepy I was.

My position is to look at it all from the perspective that people should be allowed to try PAP to find out whether or not they are sleepier than they think.

But I've always been a dreamer whose connection to reality is tenuous, at best.

But you know that.

I always felt that those diagnosed are a small fraction of those who actually have it. It is an "invisible" (but hardly inaudible) epidemic since the beginning of humanity.

When the awareness of its prevalence becomes reality, many more treatment options (good ones and quackery) will appear!

D.H. wrote: ↑

Wed Jan 30, 2019 6:06 pm

epidemic since the beginning of humanity.

Unlikely. Evolution (growth in size) of the human brain and switch to a diet based on agriculture have caused anatomical changes to the skull that result in much higher incidence of SDB.

jnk... wrote: ↑

Wed Jan 30, 2019 5:51 pm

I consider Epworth subjective by its very nature. It's just a fancy way of asking a patient, in detail, "Are you sleepy?" from my point of view.

Agreed. Specifically, differentiating sleepiness from fatigue, and that is a critical point.

HypnoLaus is a study of the general population. Indeed, the 2121 patients had a average ESS of 6. While a single ESS should be placed under close scrutiny and viewed in context with the rest of the patient assessment, IMO if you're looking at a pile of 2121 of them you have enough data to call that objective. However, I will be happy to temper that down to "extremely strong evidence".

So what's the real message of HypnoLaus? Let him tell us:

In previous studies, even sleep-disordered breathing of the lowest severity (apnoea-hypopnoea index >5 events per h) was associated with hypertension or depression. However, we noted these associations mostly in the upper quartile of severity (apnoea-hypopnoea index >20·6 events per h). Since current recording techniques and scoring criteria are more sensitive than those used previously, this finding strongly suggests that the definition of sleepdisordered breathing should be revised. Indeed, in our study, almost every individual had some degree of sleepdisordered breathing, and an increasing apnoeahypopnoea index was associated with augmented prevalence of comorbid diseases. These results reinforce the idea that, instead of using the arbitrary diagnostic threshold of the apnoea-hypopnoea index, sleep-disordered breathing should be considered as a disease characterised by a severity spectrum, akin to blood pressure or cholesterol levels. (B&I me)

Morbius wrote: ↑

Thu Jan 31, 2019 5:17 am

Specifically, differentiating sleepiness from fatigue

I believe that either can be a symptom of sleep-disordered breathing. Fatigue may be the key symptom in the young female UARS-ish phenotype. And my position is that people who have had SDB for years often do not recognize either symptom in themselves effectively enough to report it/them in any questionnaire. Payers don't get that. But many respected practitioners do, I believe. Thus an industry built on fudging numbers.

Morbius wrote: ↑

Thu Jan 31, 2019 5:17 am

a study of the general population.

I believe many in the population might benefit from PAP despite the fact that medical science has not yet developed a practical, inexpensive, effective way to identify all the people who might benefit from PAP. And I believe this study can be used as ammunition to support that position. The line in the sand made by payers that someone with an AHI of 4.99999999 will obviously not benefit from PAP and someone with an AHI of 5.0000001 will is not a sane position for deciding who gets to try to improve their lives by improving their sleep. Especially is that so when there are more definitions for hypopnea than there are hot dog carts in Midtown.

The real message for the medical community may be about refining definitions. But the larger message for the planet is that people should have the right to get to something that improves sleep and life itself without playing games with definitions that people only pretend make sense, in the larger picture.

"What numbers should we use to define a subset of a disease?" is all well and good as a question, for those who think white coats are a fashion statement. But, "How can we help people we don't have the tools yet to identify?" is still a valid question to be explored outside the turf wars of the medical communities. That is why the larger question for me is more one of, "Should this person get the chance to find out whether PAP helps?" and not so much, "What specifically defined condition does this person have so I can explain it to payers in a way they understand?"

When medical people find themselves in the situation of being required to be the gatekeepers who decide who gets denied an opportunity to try a simple mechanical fix for a simple anatomical problem with profound health and safety repercussions, that distorts medicine in a way I personally am not comfortable with. It makes a test a basis for potentially hurting rather than for potentially helping. The doc has his view of that. Payers have their view of that. But patients get caught in the middle and end up on the losing end.

In my opinion as just some guy in a funny hat on the Internet.

Well if you want to see somebody in a funny hat...

IMO sleepy (or fatigued) people who visit CPAPTalk should be aware of the adage:

"If the only tool in your toolbox is a hammer then everything becomes a nail".

jnk... wrote: ↑

Thu Jan 31, 2019 7:32 am

Payers

^This shows from time to time in your posts. Please understand that we are the payers. Insurance companies aren't allowed to print money. They can only get it from us.

jnk... wrote: ↑

Thu Jan 31, 2019 7:32 am

a practical, inexpensive, effective way to identify all the people who might benefit from PAP.

^You're on the right track with that. So is medical science - for examples, HSTs and diagnostic home APAPs. Apple Watch may soon tackle it.

Try not to let the standard health care definitions throw you, CG.

payer: in health care, generally refers to entities other than the patient that finance or reimburse the cost of health services. In most cases, this term refers to insurance carriers, other third-party payers, or health plan sponsors (employers or unions). -- Mosby's Dental Dictionary, 2nd edition. © 2008

And in many cases in standard medicine, "response to therapy" is the very best retroactive diagnostic tool available when it comes to relatively inexpensive treatment options. That's why the focus needs to be lowering price of PAP trials. In my opinion.

Morbius wrote: ↑

Thu Jan 31, 2019 9:06 am

. . . "If the only tool in your toolbox is a hammer then everything becomes a nail".

My point is that if a cheap tool (such as a simple hammer) solves the problem, make that tool available at hardware stores without making homeowners bring in a signed permission slip from a licensed contractor.

jnk... wrote: ↑

Thu Jan 31, 2019 9:35 am

Morbius wrote: ↑

Thu Jan 31, 2019 9:06 am

. . . "If the only tool in your toolbox is a hammer then everything becomes a nail".

My point is that if a cheap tool (such as a simple hammer) solves the problem, make that tool available at hardware stores without making homeowners bring in a signed permission slip from a licensed contractor.

nice analogy jnk ~~~

~~~you nailed it

Grace~~~ wrote: ↑

Thu Jan 31, 2019 11:35 am

nice analogy jnk

Thanks, Grace.

Just remember that even when my posts seem to make sense, that still doesn't mean I have any idea what I'm talking about.

Morbius has wrung more water out of his mittens than I've sailed over.