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The Tale of Two Patients

Not all sleep diagnostics are created equal

What makes True Sleep Diagnostics different? I am sure that question has crossed your mind as many times as we have been asked the question. My reply . . . "Yes, I'm glad you asked." All sleep labs perform the same diagnostic tests; whether in-lab or home sleep apnea test. The difference arises when the information is reviewed, dissected, explained, and treated. The following story is one of many true stories comparing outcomes of a competing sleep entity with True Sleep Diagnostics. In this story, two patients who were previously prescribed continuous positive airway pressure (CPAP) to treat their previously diagnosed sleep apnea, presented with complaints associated with sleep apnea despite being treated with CPAP. The names have been changed because HIPPA is life.

Patient A; 43 year old male, 75" tall, 225 lbs. Previously prescribe Auto CPAP 8 - 20 cm H2O to quell an AHI of 11.7. Patient never underwent in-lab study for CPAP; his diagnostic study was a home sleep apnea test (HSAT or HST) performed in another state.

Patient A presented to his new sleep clinic with HSAT report to discuss treatment options. At this time, Patient A presented with snoring, witnessed apnea, waking with gasping, GERD, nocturnal heart palpitations, difficulty maintaining sleep and severe daytime sleepiness - falling asleep at red lights. The provider prescribes Patient A an Auto CPAP 8 - 20 cm H2O and requests a call if daytime sleepiness does not improve.

Fast forward 5 years. Patient A presented to the same provider with excessive daytime sleepiness, vivid dreams throughout the night (common of sleep deprivation), and weight gain of 3 pounds. His CPAP download reports great compliance with an average of 6.3 hours of use per night and estimated AHI of 0.3. His average pressure reported was 8 cm H2O. The provider orders a daytime test called a multiple sleep latency test (MSLT) to see if the patient has narcolepsy despite being "successfully" treated with CPAP.

Prior to the daytime MSLT, it is best to have an overnight diagnostic study to ensure the patient has at least 6 hours of quality sleep without sleep disordered breathing, frequent arousals, or frequent periodic limb movements. Patient A underwent diagnostic study with CPAP prior to the MSLT. Upon review of the diagnostic study, frequent flow limitation and arousals were noted, however apneas and hypopneas were not. The sleep quality was atrocious, and Patient A's pulse rate danced all over the place all night long. Now, since the AHI did not reveal sleep apnea, the upper airway resistance syndrome was disregarded. In the morning, Patient A underwent a MSLT and was diagnosed with hypersomnolence (excessive daytime sleepiness). His treatment plan was continue CPAP at 8 cm H2O and begin taking a prescribed stimulant.

Patient B; 52 year old male, 71" tall, 215 lbs. Previously diagnosed with severe sleep apnea and prescribed CPAP 18 cm H2O. Patient B's diagnostic studies was unavailable.

Patient B presented to his primary care provider with excessive daytime sleepiness and feeling like crap despite being compliant with CPAP. Patient B's insurance carried a very high deductible, and they explained to their primary care provider that they could not afford an in-lab diagnostic study with CPAP. Patient B's provider contacted an office who contracts True Sleep Diagnostics for HSAT; questioning if HSAT could be performed with CPAP. The answer was yes! (Side note; we believe in-lab testing should be done for every patient for a bevy of reasons, especially CPAP, however HSAT does have an economical value.)

Patient B was set up with a home sleep apnea test that included an attachment to record breathing from the CPAP machine. Upon review of the HSAT with CPAP, Patient B's AHI was 0.3. How shocking right!? 1 apnea and 2 hypopneas were found in 532.3 minutes of the study. But wait . . . severe flow limitation and frequent pulse rate fluctuation, in conjunction, were seen as well (exactly like Patient A). The study findings were discussed with True Sleep's interpreting physician. True Sleep suggested BiLevel to alleviate flow limitation; to which the interpreting physician agreed.

True Sleep explained the plan to Patient B. Patient B stated again, he could in no way afford an in-lab study. True Sleep acquired a BiLevel machine from a local durable medical equipment company (DME) for trial. Patient B was educated on BiLevel and given a plan. True Sleep would set the BiLevel machine, adjust it as needed to alleviate sleep disordered breathing, and improve quality of life. True Sleep informed Patient B the trial would last from 2 - 4 weeks.

After 2 days, True Sleep called Patient B to ask, 1) What does the machine report for AHI and 2) How do you feel. Patient B stated the machine reported AHI was 7.2 with 8 hours of sleep time. Patient B also reported feeling the same as before. True Sleep adjusted the settings. After 2 more days, Patient B reported an AHI of 31.9 with 8 hours of sleep time, yet he felt better and did not wake repeatedly (Side note: this was due to central apneas caused by the BiLevel setting). True Sleep adjusted the setting. 1 day later, the magic happened. Patient B contacted True Sleep and exclaimed, " I feel rested, I feel pretty good. And the machine reported AHI was 0.5." After 2 days, Patient B communicated they were feeling great and the machine reported AHI was 0.5 and 0.6 for both days. 3 months later, True Sleep contacted the patient for status update. Patient B replied, "Things have been very good, and I feel very rested. I appreciate all of your help."

2 patients with ineffective positive pressure treatments seeking resolve.

Patient A was mistreated from the start, by issuing an Auto CPAP. Blog on why we do not favor Auto CPAP is soon to come. Patient A was patched with medication (side effects, withdrawal, have to remember to take it, how long is the action of the medication existent in the body?). Patient A still has a sleep disordered breathing problem, and therefore still is susceptible to high blood pressure, stroke, heart dysfunction, cognition impairment, etc. Why? The underlying cause of his daytime sleepiness was not resolved. The prescribed stimulant does not correct the sleep disordered and the physiological detriment associated.

Patient B's nocturnal breathing was fully assessed (even though with HSAT) and treated accordingly. Not only does Patient B feel great, his body is not killing itself to keep him alive.

How did True Sleep know BiLevel would resolve the sleep disordered breathing? CPAP does not necessarily eliminate sleep disordered breathing, even if it eliminates apneas and hypopneas. CPAP serves as an airway stint. Depending on upper airway/mid-face architecture, the delivery of the "air" stint may not be enough to prevent soft tissue from collapsing during inspiration; hence the flow limitation during its use. When flow limitation is noted while using CPAP, more breathing volume in addition to the stint can possibly eliminate the sleep disordered breathing. To add more breathing volume, two levels of positive pressure are used; called BiLevel.

The diagnostic assessments performed by and decisions made by True Sleep are trusted by sleep physicians who specialize in pulmonology. True Sleep's roots are buried in mechanical ventilation from previous patient care in respiratory therapy. Via experience and knowledge of flow waveform dynamics, True Sleep is very successful in assessing and controlling respiratory events with any mode of positive pressure ventilation. True Sleep understands every patient is different, and does not treat them with a cookie cutter approach to diagnostics or treatment. Numerous patients complain their CPAP "doesn't work". That can be both true and false. True, the CPAP may not work for the patient, yet because the settings are not optimal. We always suggest undergoing a diagnostic study to ensure the proper setting is configured. That reality is expensive, however not all sleep diagnostics are created equal.

If you or your patients feel excessively tired during the day, have difficulty focusing, or have difficulty staying asleep, have an evaluation from a sleep physician. You may have a sleep disorder and not realize it.

Better Sleep is a Better You!

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