Pulmonary vs. neurology sleep specialist

I've had unsuccessful CPAP therapy since I started nearly 2 years ago, despite have excellent numbers (AHI, etc.)
So, I've been thinking finding a new doctor to get new opinions or treatment strategies; switching sleep specialists.

Someone's response to my other thread viewtopic/t107086/No-slow-waverestorative-sleep.html
sparked a new thought. My current sleep specialist is a pulmonary doctor. Maybe I should find a sleep specialist with a neurology background? Are there endocronologist sleep specialists?

Does anyone have experiences to share about the pros and cons of treatment with different types of specialists?

Your other post said that you had no slow wave sleep. Is that literally true (NREM3 = 0.0)?

Was there evidence of alpha intrusion on any of your sleep studies?

I don't know what alpha intrusion is.

My recent CPAP statistics 7/4/15 to 8/4/15 report:

AutoSet Devise ResMed S9
minimum pressure 5.0
maximum pressure 13.0
8.7 median pressure; 95% percentile 11.4
3.0 median leak; 95% percentile 14.4
apnea index 1.8; hypopnea index 0.3
obstructive 0.6; central 1.2
median daily usage 7:08
average daily usage 6:42
% used days >= 4 hours: 87
EPR: Full time, level 3

Key #s from recent titration study

(I had one 2 years ago so this was ordered due to my fatigue and other issues)
(Used same brand of mask as the one at home, Quattro, but asked tech to look at mask fit. He suggested size small. So the mask was different than the one used corresponding with the data above, where I used Quattro size medium.) Of course the machine was different as this was the sleep center's machine.

Sleep Time Statistics
464.5 time in bed
388.5 total sleep time
83.6% sleep efficiency
24.5 sleep onset
84 REM latency
235 TST supine
153.5 TST side/prone

Respiratory and Oximetry Statistics
2.6 AHI
3.4 RDI
SpO2 <- 88% (minutes) = 0
88 Lowest O2

Arousal Statistics
Spontaneous 40 total; 6.2 index
Respiratory 8 total; 1.2 index
PLM 0

Sleep Stage Statistics
Stage N1-latency 18.5 minutes; % TST 04.8% *I don't know what TST means
Stage N2-Latency 262.5 minutes; % TST 67.6%
State N3-Latency 2.5 minutes; % TST 00.6%
REM 105 minutes; % TST 27.0%

PLM Statistics
All zero

EKG Summary
72.5 heart rate wake
71.0 heart rate steady average

Tech Notes
Snoring was not heard
An irregular rhythm was seen in the EKG
There were no significant abnormalties observed in EEG or EMG

Treatment Interval Report
Don't know which numbers were relevant, but I had no obstructive apnea counts at all.

I/E/O (don't know what this means):
5/5/0/0 apnea count; 0 obst.; 2 central; 1 mixed
6/6/0/0 apnea count: 0 obstructive; 2 central; 0 mixed
7/7/0/0 apnea count: 0 obstructive; 5 central; 0 mixed

..maybe I should scan document and post screen shot of chart of treatment interval report. If anyone is willing to look at it, I will.

"There were no significant abnormalties observed in EEG or EMG"... therefore no alpha intrusions of note or if there was anything at all, it would probably have been called artefact (machine junk).

I personally would go the neuro. route because that's what I know from work and because it sounds like you won't feel satisfied without that input, but it so depends on the individual and their training... the wrong one could be worse than useless, the right one terrific.

Julie wrote:"There were no significant abnormalties observed in EEG or EMG"... therefore no alpha intrusions of note or if there was anything at all, it would probably have been called artefact (machine junk).

Thanks very much for clearing that up.

Just an opinion, but a neurologist could be of help if one has issues in addition to obstructive sleep apnea that are not satisfactorily address by a sleep doctor without a neurology specialty. That said, a pulmonary/sleep doctor was more current and helpful in dealing with my neurological problem of limb movements than the several neurologists I'd seen over the years. Unless your doctor has proven themselves unwilling to be of help, I probably wouldn't jump ship without knowing it's a need. Best wishes figuring out what's best for you.

Getting another opinion should not constitute 'jumping ship' from your other doctor - it's done every day and only if you choose to jump on a permanent, full time basis would it be seen that way.

Morbius wrote:

Julie wrote:"There were no significant abnormalties observed in EEG or EMG"... therefore no alpha intrusions of note or if there was anything at all, it would probably have been called artefact (machine junk).

Thanks very much for clearing that up.

Perhaps I have another question.

Since those comments were in the

Tech Notes

Do we know if the tech would recognize alpha intrusion if they saw it?

Unless your doctor has proven themselves unwilling to be of help, I probably wouldn't jump ship without knowing it's a need.

In my case, it might be that he doesn't have the capacity to help due to clinical judgment, lack of objectivity, or other reasons.

For example, on the first visit with him, he chose to discuss CBT therapy during the entire visit, which was nothing that I hadn't already found online. He could have helped by looking at the data, reviewing my prior study, or any number of things. He thought a discussion about CBT--a treatment I told him I cannot even afford to pay for--was the most important thing to do.

Do we know if the tech would recognize alpha intrusion if they saw it?

Possibly. He was very sophisticated, I think he would have. I had read that alpha intrusion normally occurs in stage 4 sleep. My study revealed I only slept for about 2 minutes in stage 3 or 4 sleep, so maybe I never entered stage 4, the window of opportunity for the alpha intrusions.

Getting another opinion should not constitute 'jumping ship' from your other doctor - it's done every day and only if you choose to jump on a permanent, full time basis would it be seen that way.

Is there some kind of stigma involved with switching doctors?

I can't find my study that was done a couple of weeks prior to the one I posted data for, but it showed I was in Stage 1 sleep for 95% of the time, with REM at 5%. I had mostly hypopneas, wasn't eligible for CPAP treatment for insurance guidelines.

I also need to find the sleep study I did 2 years ago, although it was sent to this doctor. There is a note in my record that I had to quit the study early due to shortness of breath. I just had an ER trip for SOB prior to this visit with the pulmonary sleep specialist (no diagnosis was found); I told him my internist suggested breathing tests so he ordered them. It wasn't scheduled until the end of this year, so i'm thinking I should go somewhere else. I've had this problem off/on for a couple of years now.

OceanBlue wrote:

Do we know if the tech would recognize alpha intrusion if they saw it?

Possibly. He was very sophisticated, I think he would have. I had read that alpha intrusion normally occurs in stage 4 sleep. My study revealed I only slept for about 2 minutes in stage 3 or 4 sleep, so maybe I never entered stage 4, the window of opportunity for the alpha intrusions.

The new nomenclature gets rid of Stage 4, NREM3 includes all SWS. A thought might be that you had a pile of solid NREM2 with SWS-frequency but lacking amplitude (a technical glitch).

Anyway, it wouldn't hurt to go back and review studies looking for alpha. It's presence (or absence) might support your (a?) position.

OceanBlue wrote:

Getting another opinion should not constitute 'jumping ship' from your other doctor - it's done every day and only if you choose to jump on a permanent, full time basis would it be seen that way.

Is there some kind of stigma involved with switching doctors?

My comment was not in regards to stigma. There is no stigma in getting a 2nd opinion. Or changing doctors if it is not habitual. My thoughts were more about logistics and about the possibility of the jumping from the frying pan into the fire. Just because a doctor is a neurologist won't necessarily make them more helpful to your situation. Almost every time I've changed doctors (sometimes due to disagreement, others due to insurance changes or a location change), the new doctor (especially sleep doctors) like to start from scratch with repeat sleep studies. Last time I had to simply refuse as my studies were recent. I once had a GP who had failed to help me. When I specifically asked him to not stop until he found answers for me, he came through for me. Turned out to be a long standing beneficial relationship.

Obviously your situation requires a change. If you feel your current doctor is unable for whatever reason to be that change, don't hesitate to do what you need to do to get the help you need. I wouldn't want you to take my prior input as saying you shouldn't change doctors. I just know that 3 neurologists who were not that helpful came from highly reputable groups. It not always a quick fix. I was speaking out of that experience. I hope you find help for your sleep.

Anyway, it wouldn't hurt to go back and review studies looking for alpha. It's presence (or absence) might support your (a?) position.

Ok, I have to get the full studies. I only have one of the summaries. Thanks

Just because a doctor is a neurologist won't necessarily make them more helpful to your situation.

Yes, I'm leaning towards not pursuing that route just yet. I will see if people here can help interpret data before deciding next steps.