Having issues convincing doctor I have Either Idiopathic CSA, or Mixed CSA. Help!
I do not seem to be making progress with my sleep doctor because he keeps ignoring my Central Sleep Apnea component revealed in my very first non-CPAP sleep study. I present 25% OSA/ 75% CSA in my initial sleep study. However, after I finished with my follow up meeting with this doctor, he recommended a CPAP because at the time they could not do a titration study due to covid, so I took the CPAP as an option. Because of my insomnia and CSA though, I ended up having to go into my PCP at another clinic branch, and demand that they give me sonata and that my CSA was not addressed by this other doctor. Eventually, I did get the titration study done. I have yet to see the results, but will be having an E-visit with my doctor on April 4. The titrationist indicated that they did not move on to the ASV or Bipap. So unfortunately, I am stuck with a A/CPAP. Also, on the night of the titration, they gave me an ambien, which I think affected the outcome of the study. Right after I got on the sonata, and about a month before the titration, I had problems complying with the machine itself and the mask, so in order to still comply with insurance, I wore the mask during the day while I worked from home, and had the mask off at night and exclusively focused on using the sonata to get my sleep cycle back on track. It now is (sort of) back on track.
Now i am having lower AHIs on average, but i think it is due to the sonata. But the sonata (5mg) only helps with sleep onset and seems to wear off halfway through my sleep cycle and centrals start to re-emerge near the morning, causing interruptions in my longer, morning REM cycles. I'm dreaming for the first time in decades and I am having nightmares. Its awesome, but it sucks because I need to be on a stronger amount I believe of ambien, or some sort of medication. Diamox?
Has anyone else encountered sleep doctors denying the reality of CSA? I don’t have a lot of time in this virtual visit, to make my case. Can someone take a fresh look at my sleep study, and tell me how i can quickly get to the point and how do i politely put my doctor on the spot? It's now or never with this guy and I think I need meds, and probably a whole new sleep study without medication that night. The problem is just, when I'm having complete insomnia, its impossible to sleep or know when I'll sleep, which doesn't help the sleep study. But if I just take an ambien I'm out cold, with low or no CSAs. But unisom, and melitonin do absolutely nothing. help!
Sleep study here:
Progress Notes
Progress Notes by (blank) (blank) at 9/27/2021 3:30 PM
Message sent to Sleep Specialist to schedule acti-watch for patient.
(blank) (blank), MA
Progress Notes by (blank), MD, MD at 9/27/2021 3:30 PM
(blank) is a 33 year old male who is being evaluated via a billable video visit.
The patient has been notified of following:
"This video visit will be conducted via a call between you and your physician/provider. We have found that certain health care needs can be provided without the need for an in-person physical exam. This service lets us provide the care you need with a video conversation. If a prescription is necessary we can send it directly to your pharmacy. If lab work is needed we can place an order for that and you can then stop by our lab to have the test done at a later time.
Video visits are billed at different rates depending on your insurance coverage. Please reach out to your insurance provider with any questions.
If during the course of the call the physician/provider feels a video visit is not appropriate, you will not be charged for this service."
Patient has given verbal consent for Video visit? Yes
How would you like to obtain your AVS? Mail a copy
If you are dropped from the video visit, the video invite should be resent to: Text to cell phone: -
Will anyone else be joining your video visit? No
If patient encounters technical issues they should call 612-672-7266
Video-Visit Details
Type of service: Video Visit
Video Start Time: 3:30pm
Video End Time: 4pm
Originating Location (pt. Location): Home
Distant Location (provider location): M HEALTH FAIRVIEW SLEEP CENTER MINNEAPOLIS
Platform used for Video Visit: AmWell
Virtual visit for review of sleep testing results.
Assessment:
- Moderate OSA (AHI 21.3, RDI 27.9) with sleep-associated hypoxemia. Prolonged desaturations seen in supine REM.
- Rare PLM's on PSG
- Persistent muscle twitching / fasiculations arising from sleep and note from patient of other people with alopecia universalis reporting similar sleep concerns. DDx is broad including PLM's, hypnic jerks, propriospinal myoclonus, unknown.
Plan:
- Start CPAP auto-titrate 5-15 cm H2O
- Actigraphy x 2 weeks to better assess sleep-wake pattern and if evidence of increased body movements during sleep
SUBJECTIVE:
(blank) is a 33 year old year old male.
Pertinent PMHx of ADD, obesity, HTN, depression, anxiety, alopecia universalis.
Appointment note mentions chronic insomnia, hypnic jerks, reportedly already practicing sleep hygiene.
7/19/2021 -he feels that he has had issues with insomnia and his sleep in general for many years, almost since birth. But he was prompted to seek an evaluation at this time since working from home remotely with Covid and discussing with his family about their sleep in relation to his sleep potentially had issues.
He feels that he has had challenges with falling asleep and staying asleep for as long as he would remember, since childhood. He did not necessarily identify this as an issue or abnormal since it has been this way for as long as he can remember. But this recently changed after he was reading and talking with his alopecia universalis support group and had brought up about many different sleep disorders that have been linked with that, including hypnic jerks. He then spoke with his parents about their sleep, and was surprised by how quickly they would fall asleep and in general lack of issues. He does feel that his sleep affects him during the day but feeling more tired, but denies any inappropriate sleepiness.
Given the variability of the sleep, he finds it hard to describe his typical sleep pattern today. He would give his sleep in general a grade of "C or C-", but on nights that he does not have perceived hypnic jerks that his sleep quality be closer to a "B or B-". It appears that most nights he is going to bed around 11 PM, but time to fall asleep is unknown and unclear. He feels that potentially 1 or more nights per week that he perceives little to no sleep while spending the entire night in bed. He is also unclear about what time he gets up to start his day. He does not seem to take regular daytime naps.
He has been trying to take his sleep more seriously, again discussing this with his alopecia support group. He has purchased and started using a light box in the morning. He has tried multiple over-the-counter sleep aids including melatonin in the past, but not felt to have appreciable benefit. It is unknown the exact timing or dosage of these.
We discussed his reported hypnic jerks in more detail. He reports he is predominantly happen as he is attempting to initiate sleep, occur most nights, and can seem to happen multiple times in a given attempt to fall asleep. He describes this as feeling that he is falling. He states that sometimes these can be visible, but other times have been very subtle work he does not believe other people would perceive the muscle activity.
He believes he does snore, but he is unsure if it is loud or regular. He is unaware of any reports of observed apnea. He has woken up with a gasping sensation before.
He was diagnosed with hypertension and started medications in his early 20s, there does not appear to be a concern currently for secondary hypertension.
Today - We reviewed the PSG results in detail. We also discussed the unclear etiology of the jerky movements arising from sleep and potentially disrupting sleep.
ISI Total Score: 26
SLEEP STUDY INTERPRETATION
DIAGNOSTIC POLYSOMNOGRAPHY REPORT
Patient: (blank), (blank)
Date of Birth: 6/5/1988
Study Date: 9/15/2021
MRN: 0007233408
Referring Provider: self
Ordering Provider: (blank) MD (blank)
Indications for Polysomnography: The patient is a 33 year old Male who is 6' 2" and weighs 245.0 lbs. His BMI is 31.4, Epworth sleepiness scale - and neck circumference is - cm. Relevant medical history includes chronic insomnia, ADD, obesity, HTN, depression, anxiety, alopecia universalis. A diagnostic polysomnogram was performed to evaluate for sleep apnea.
Polysomnogram Data: A full night polysomnogram recorded the standard physiologic parameters including EEG, EOG, EMG, ECG, nasal and oral airflow. Respiratory parameters of chest and abdominal movements were recorded with respiratory inductance plethysmography. Oxygen saturation was recorded by pulse oximetry. Hypopnea scoring rule used: 1B 4%.
Sleep Architecture: Fragmented, increased arousal index, supine REM was observed.
The total recording time of the polysomnogram was 532.0 minutes. The total sleep time was 454.5 minutes. Sleep latency was increased at 30.5 minutes with the use of a sleep aid (zolpidem 10mg). REM latency was 57.5 minutes. Arousal index was increased at 35.6 arousals per hour. Sleep efficiency was normal at 85.4%. Wake after sleep onset was 46.5 minutes. The patient spent 5.2% of total sleep time in Stage N1, 47.4% in Stage N2, 21.2% in Stage N3, and 26.2% in REM. Time in REM supine was 57.5 minutes.
Respiration: Moderate OSA (AHI 21.3, RDI 27.9) with sleep-associated hypoxemia. Prolonged desaturations seen in supine REM.
Events ─ The polysomnogram revealed a presence of 25 obstructive, 71 central, and 1 mixed apneas resulting in an apnea index of 12.8 events per hour. There were 44 obstructive hypopneas and 20 central hypopneas resulting in an obstructive hypopnea index of 5.8 and central hypopnea index of 2.6 events per hour. The combined apnea/hypopnea index was 21.3 events per hour (central apnea/hypopnea index was 12.0 events per hour). The REM AHI was 25.7 events per hour. The supine AHI was 34.3 events per hour. The RERA index was 6.6 events per hour. The RDI was 27.9 events per hour.
Snoring – was reported as moderate to loud.
Respiratory rate and pattern – was notable for normal respiratory rate and pattern.
Sustained Sleep Associated Hypoventilation – Transcutaneous carbon dioxide monitoring was not used, however significant hypoventilation was not suggested by oximetry.
Sleep Associated Hypoxemia – (Greater than 5 minutes O2 sat at or below 88%) was present. Baseline oxygen saturation was 93.8%. Lowest oxygen saturation was 77.6%. Time spent less than or equal to 88% was 5.9 minutes. Time spent less than or equal to 89% was 8.4 minutes.
Movement Activity: Rare PLM’s observed.
Periodic Limb Activity – There were 4 PLMs during the entire study. The PLM index was 0.5 movements per hour. The PLM Arousal Index was 0.5 per hour.
REM EMG Activity – Excessive transient/sustained muscle activity was not present.
Nocturnal Behavior – Abnormal sleep related behaviors were not noted during/arising out of NREM / REM sleep.
Bruxism – None apparent.
Cardiac Summary: Appears NSR.
The average pulse rate was 68.6 bpm. The minimum pulse rate was 48.9 bpm while the maximum pulse rate was 110.2 bpm.
Assessment:
Moderate OSA (AHI 21.3, RDI 27.9) with sleep-associated hypoxemia. Prolonged desaturations seen in supine REM.
Rare PLM’s observed.
Recommendations:
Consider repeat polysomnography with full night titration of positive airway pressure therapy for the control of sleep disordered breathing.
Based on the presence of moderate obstructive sleep apnea and excessive daytime sleepiness, treatment could be empirically initiated with Auto─titrating PAP therapy with a range of 5 to 15 cmH2O. Recommend clinical follow up with sleep management team.
Patient may be a candidate for dental appliance through referral to Sleep Dentistry for the treatment of obstructive sleep apnea and/or socially disruptive snoring.
If devices are not acceptable or effective, patient may benefit from evaluation of possible surgical options. If he is interested, would recommend referral to specialized ENT-Sleep provider.
Advice regarding the risks of drowsy driving.
Suggest optimizing sleep schedule and avoiding sleep deprivation.
Weight management (if BMI > 30).
Pharmacologic therapy should be used for management of restless legs syndrome only if present and clinically indicated and not based on the presence of periodic limb movements alone.
Diagnostic Codes:
Obstructive Sleep Apnea G47.33
Sleep Hypoxemia/Hypoventilation G47.36
_____________________________________
Electronically Signed By: (blank) (blank), MD (9/26/2021)
10 point ROS of systems including Constitutional, Eyes, Respiratory, Cardiovascular, Gastroenterology, Genitourinary, Integumentary, Muscularskeletal, Psychiatric were all negative except for pertinent positives noted in my HPI.
Current Outpatient Medications
Medication
Sig
Dispense
Refill
•
zolpidem (AMBIEN) 10 MG tablet
Take 1 tablet (10 mg) by mouth nightly as needed for sleep . Bring with you to sleep study.
1 tablet
0
OBJECTIVE:
There were no vitals taken for this visit.
Physical Exam
---
This note was written with the assistance of the Dragon voice-dictation technology software. The final document, although reviewed, may contain errors. For corrections, please contact the office.
(blank) (blank), MD
Sleep Medicine
M Health Fairview Sleep Centers - University of MN (612-273-3396)
M Health Fairview Sleep Centers - Hibbing (218-362-6558)
Now i am having lower AHIs on average, but i think it is due to the sonata. But the sonata (5mg) only helps with sleep onset and seems to wear off halfway through my sleep cycle and centrals start to re-emerge near the morning, causing interruptions in my longer, morning REM cycles. I'm dreaming for the first time in decades and I am having nightmares. Its awesome, but it sucks because I need to be on a stronger amount I believe of ambien, or some sort of medication. Diamox?
Has anyone else encountered sleep doctors denying the reality of CSA? I don’t have a lot of time in this virtual visit, to make my case. Can someone take a fresh look at my sleep study, and tell me how i can quickly get to the point and how do i politely put my doctor on the spot? It's now or never with this guy and I think I need meds, and probably a whole new sleep study without medication that night. The problem is just, when I'm having complete insomnia, its impossible to sleep or know when I'll sleep, which doesn't help the sleep study. But if I just take an ambien I'm out cold, with low or no CSAs. But unisom, and melitonin do absolutely nothing. help!
Sleep study here:
Progress Notes
Progress Notes by (blank) (blank) at 9/27/2021 3:30 PM
Message sent to Sleep Specialist to schedule acti-watch for patient.
(blank) (blank), MA
Progress Notes by (blank), MD, MD at 9/27/2021 3:30 PM
(blank) is a 33 year old male who is being evaluated via a billable video visit.
The patient has been notified of following:
"This video visit will be conducted via a call between you and your physician/provider. We have found that certain health care needs can be provided without the need for an in-person physical exam. This service lets us provide the care you need with a video conversation. If a prescription is necessary we can send it directly to your pharmacy. If lab work is needed we can place an order for that and you can then stop by our lab to have the test done at a later time.
Video visits are billed at different rates depending on your insurance coverage. Please reach out to your insurance provider with any questions.
If during the course of the call the physician/provider feels a video visit is not appropriate, you will not be charged for this service."
Patient has given verbal consent for Video visit? Yes
How would you like to obtain your AVS? Mail a copy
If you are dropped from the video visit, the video invite should be resent to: Text to cell phone: -
Will anyone else be joining your video visit? No
If patient encounters technical issues they should call 612-672-7266
Video-Visit Details
Type of service: Video Visit
Video Start Time: 3:30pm
Video End Time: 4pm
Originating Location (pt. Location): Home
Distant Location (provider location): M HEALTH FAIRVIEW SLEEP CENTER MINNEAPOLIS
Platform used for Video Visit: AmWell
Virtual visit for review of sleep testing results.
Assessment:
- Moderate OSA (AHI 21.3, RDI 27.9) with sleep-associated hypoxemia. Prolonged desaturations seen in supine REM.
- Rare PLM's on PSG
- Persistent muscle twitching / fasiculations arising from sleep and note from patient of other people with alopecia universalis reporting similar sleep concerns. DDx is broad including PLM's, hypnic jerks, propriospinal myoclonus, unknown.
Plan:
- Start CPAP auto-titrate 5-15 cm H2O
- Actigraphy x 2 weeks to better assess sleep-wake pattern and if evidence of increased body movements during sleep
SUBJECTIVE:
(blank) is a 33 year old year old male.
Pertinent PMHx of ADD, obesity, HTN, depression, anxiety, alopecia universalis.
Appointment note mentions chronic insomnia, hypnic jerks, reportedly already practicing sleep hygiene.
7/19/2021 -he feels that he has had issues with insomnia and his sleep in general for many years, almost since birth. But he was prompted to seek an evaluation at this time since working from home remotely with Covid and discussing with his family about their sleep in relation to his sleep potentially had issues.
He feels that he has had challenges with falling asleep and staying asleep for as long as he would remember, since childhood. He did not necessarily identify this as an issue or abnormal since it has been this way for as long as he can remember. But this recently changed after he was reading and talking with his alopecia universalis support group and had brought up about many different sleep disorders that have been linked with that, including hypnic jerks. He then spoke with his parents about their sleep, and was surprised by how quickly they would fall asleep and in general lack of issues. He does feel that his sleep affects him during the day but feeling more tired, but denies any inappropriate sleepiness.
Given the variability of the sleep, he finds it hard to describe his typical sleep pattern today. He would give his sleep in general a grade of "C or C-", but on nights that he does not have perceived hypnic jerks that his sleep quality be closer to a "B or B-". It appears that most nights he is going to bed around 11 PM, but time to fall asleep is unknown and unclear. He feels that potentially 1 or more nights per week that he perceives little to no sleep while spending the entire night in bed. He is also unclear about what time he gets up to start his day. He does not seem to take regular daytime naps.
He has been trying to take his sleep more seriously, again discussing this with his alopecia support group. He has purchased and started using a light box in the morning. He has tried multiple over-the-counter sleep aids including melatonin in the past, but not felt to have appreciable benefit. It is unknown the exact timing or dosage of these.
We discussed his reported hypnic jerks in more detail. He reports he is predominantly happen as he is attempting to initiate sleep, occur most nights, and can seem to happen multiple times in a given attempt to fall asleep. He describes this as feeling that he is falling. He states that sometimes these can be visible, but other times have been very subtle work he does not believe other people would perceive the muscle activity.
He believes he does snore, but he is unsure if it is loud or regular. He is unaware of any reports of observed apnea. He has woken up with a gasping sensation before.
He was diagnosed with hypertension and started medications in his early 20s, there does not appear to be a concern currently for secondary hypertension.
Today - We reviewed the PSG results in detail. We also discussed the unclear etiology of the jerky movements arising from sleep and potentially disrupting sleep.
ISI Total Score: 26
SLEEP STUDY INTERPRETATION
DIAGNOSTIC POLYSOMNOGRAPHY REPORT
Patient: (blank), (blank)
Date of Birth: 6/5/1988
Study Date: 9/15/2021
MRN: 0007233408
Referring Provider: self
Ordering Provider: (blank) MD (blank)
Indications for Polysomnography: The patient is a 33 year old Male who is 6' 2" and weighs 245.0 lbs. His BMI is 31.4, Epworth sleepiness scale - and neck circumference is - cm. Relevant medical history includes chronic insomnia, ADD, obesity, HTN, depression, anxiety, alopecia universalis. A diagnostic polysomnogram was performed to evaluate for sleep apnea.
Polysomnogram Data: A full night polysomnogram recorded the standard physiologic parameters including EEG, EOG, EMG, ECG, nasal and oral airflow. Respiratory parameters of chest and abdominal movements were recorded with respiratory inductance plethysmography. Oxygen saturation was recorded by pulse oximetry. Hypopnea scoring rule used: 1B 4%.
Sleep Architecture: Fragmented, increased arousal index, supine REM was observed.
The total recording time of the polysomnogram was 532.0 minutes. The total sleep time was 454.5 minutes. Sleep latency was increased at 30.5 minutes with the use of a sleep aid (zolpidem 10mg). REM latency was 57.5 minutes. Arousal index was increased at 35.6 arousals per hour. Sleep efficiency was normal at 85.4%. Wake after sleep onset was 46.5 minutes. The patient spent 5.2% of total sleep time in Stage N1, 47.4% in Stage N2, 21.2% in Stage N3, and 26.2% in REM. Time in REM supine was 57.5 minutes.
Respiration: Moderate OSA (AHI 21.3, RDI 27.9) with sleep-associated hypoxemia. Prolonged desaturations seen in supine REM.
Events ─ The polysomnogram revealed a presence of 25 obstructive, 71 central, and 1 mixed apneas resulting in an apnea index of 12.8 events per hour. There were 44 obstructive hypopneas and 20 central hypopneas resulting in an obstructive hypopnea index of 5.8 and central hypopnea index of 2.6 events per hour. The combined apnea/hypopnea index was 21.3 events per hour (central apnea/hypopnea index was 12.0 events per hour). The REM AHI was 25.7 events per hour. The supine AHI was 34.3 events per hour. The RERA index was 6.6 events per hour. The RDI was 27.9 events per hour.
Snoring – was reported as moderate to loud.
Respiratory rate and pattern – was notable for normal respiratory rate and pattern.
Sustained Sleep Associated Hypoventilation – Transcutaneous carbon dioxide monitoring was not used, however significant hypoventilation was not suggested by oximetry.
Sleep Associated Hypoxemia – (Greater than 5 minutes O2 sat at or below 88%) was present. Baseline oxygen saturation was 93.8%. Lowest oxygen saturation was 77.6%. Time spent less than or equal to 88% was 5.9 minutes. Time spent less than or equal to 89% was 8.4 minutes.
Movement Activity: Rare PLM’s observed.
Periodic Limb Activity – There were 4 PLMs during the entire study. The PLM index was 0.5 movements per hour. The PLM Arousal Index was 0.5 per hour.
REM EMG Activity – Excessive transient/sustained muscle activity was not present.
Nocturnal Behavior – Abnormal sleep related behaviors were not noted during/arising out of NREM / REM sleep.
Bruxism – None apparent.
Cardiac Summary: Appears NSR.
The average pulse rate was 68.6 bpm. The minimum pulse rate was 48.9 bpm while the maximum pulse rate was 110.2 bpm.
Assessment:
Moderate OSA (AHI 21.3, RDI 27.9) with sleep-associated hypoxemia. Prolonged desaturations seen in supine REM.
Rare PLM’s observed.
Recommendations:
Consider repeat polysomnography with full night titration of positive airway pressure therapy for the control of sleep disordered breathing.
Based on the presence of moderate obstructive sleep apnea and excessive daytime sleepiness, treatment could be empirically initiated with Auto─titrating PAP therapy with a range of 5 to 15 cmH2O. Recommend clinical follow up with sleep management team.
Patient may be a candidate for dental appliance through referral to Sleep Dentistry for the treatment of obstructive sleep apnea and/or socially disruptive snoring.
If devices are not acceptable or effective, patient may benefit from evaluation of possible surgical options. If he is interested, would recommend referral to specialized ENT-Sleep provider.
Advice regarding the risks of drowsy driving.
Suggest optimizing sleep schedule and avoiding sleep deprivation.
Weight management (if BMI > 30).
Pharmacologic therapy should be used for management of restless legs syndrome only if present and clinically indicated and not based on the presence of periodic limb movements alone.
Diagnostic Codes:
Obstructive Sleep Apnea G47.33
Sleep Hypoxemia/Hypoventilation G47.36
_____________________________________
Electronically Signed By: (blank) (blank), MD (9/26/2021)
10 point ROS of systems including Constitutional, Eyes, Respiratory, Cardiovascular, Gastroenterology, Genitourinary, Integumentary, Muscularskeletal, Psychiatric were all negative except for pertinent positives noted in my HPI.
Current Outpatient Medications
Medication
Sig
Dispense
Refill
•
zolpidem (AMBIEN) 10 MG tablet
Take 1 tablet (10 mg) by mouth nightly as needed for sleep . Bring with you to sleep study.
1 tablet
0
OBJECTIVE:
There were no vitals taken for this visit.
Physical Exam
---
This note was written with the assistance of the Dragon voice-dictation technology software. The final document, although reviewed, may contain errors. For corrections, please contact the office.
(blank) (blank), MD
Sleep Medicine
M Health Fairview Sleep Centers - University of MN (612-273-3396)
M Health Fairview Sleep Centers - Hibbing (218-362-6558)
