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Permalink Reply by Sleeping Ugly on December 10, 2009 at 10:25pm

Saz,

I was thinking of going to Stanford for a sleep study to see if I have UARS. What do you mean they don't score RERAs?! Isn't Dr. Guilleminault the Father of the Modern RERA?!

BTW, do you have an opinion about the Oracle?

(Sometime I must sit down and post my story and see if anyone here can help me. I'm quite discouraged. But that's for another day when I'm only a 20 as opposed to a 40 on the Epworth...)

Thanks!

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Permalink Reply by Judy on December 11, 2009 at 8:51am

Well ... if it were me and I was starting out all over but knew what I know now ... I wouldn't even put a lotta weight on sleep lab accredidation.

I'd call my insurance and ask what local sleep labs they are contracted with, what local DME CPAP providers they are contracted with and what local sleep specialists they are contracted with.

Then I would make it a point to VISIT each sleep lab that interested me due to distance, what information they present on their website, etc. I'd ask
1] to see the rooms,
2]I'd ask about their hours and nights for studies,
3] do I consult w/their sleep doctor before and after any and all sleep studies,
4] does the doctor take the TIME to explain the results of my sleep study(s) in person,
5] does the sleep lab have a trained staff person to discuss my results w/me if the doctor doesn't usually do so,
6] who does the actual sleep study an RPSGT or a PSGT in training,
6] am I allowed any input on the equipment ordered for me BEFORE it is scripted,
7] is the sleep doctor willing to come to a meeting of the minds on the type of CPAP I want,
8] is the sleep doctor willing to script "full face, nasal cushion, nasal pillows or oro/nasal mask of patient's choice",
8] will I be told what mask I end up using the night of a titration,
9] is there a good selection of masks for me to try before selecting the mask for my titration
10] am I comfortable w/the locale of the sleep lab, i.e. noisy or scarey neighborhood, etc. I don't need the high rent district but I do want a safe, secure neighborhood and a quiet area, not next door to a busy railroad track!!

I'm sure I'll think of more questions for the "interviews" as the day goes by. Do others have any questions or things they wish they had done before the went to the sleep lab they were sent to?

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Permalink Reply by Saz RPSGT on December 11, 2009 at 10:55am

I think you're correct about Dr. Guilleminault discovering RERAs. He is on the research side though. A couple years ago I know that they were not scoring those. I learned this in a conversation with their lead technician at a conference. When I worked for them on the A.P.P.L.E.S. research study, they didn't score them there either. I'm sure that they are now adhering to the AASM 2008 changes on the sleep lab side of things. Not sure about the sleep research side.

My point had something to do with what Judy posted. Look for a lab with techs running it that have experience. At the time Stanford was known for having techs that were new and trying to get that "I worked for Stanford" thing going in their favor for future jobs. You can ask that your technician be a RPSGT. You can ask to speak with their scoring techs and ask them any of your concerns.

If any is a place to post your story...it is here! :^)

Mercy Sleep Center in Sacramento is awesome!!!! ;^) I may or may not know people that work there.... (shameless plug)

Saz

Sleeping Ugly said:

Saz,

I was thinking of going to Stanford for a sleep study to see if I have UARS. What do you mean they don't score RERAs?! Isn't Dr. Guilleminault the Father of the Modern RERA?!

BTW, do you have an opinion about the Oracle?

(Sometime I must sit down and post my story and see if anyone here can help me. I'm quite discouraged. But that's for another day when I'm only a 20 as opposed to a 40 on the Epworth...)

Thanks!

• ▶ Reply

Permalink Reply by Judy on December 12, 2009 at 12:04am

I'll tell you how it went at Mayo Clinic,Rochester, MN.

You can ASK to speak w/your scoring techs - but - at least if you have Dr Bruce A Staats, you are NOT going to be allowed to speak w/their scoring tech or ANY RPSGT!!! I tried and was told that RPSGTs are NOT medical personnel and therefore we could not speak w/them or ask them questions. (This was AFTER the bi-level titration). I even tried thru their Patient Advocate office! I made the mistake of not knowing and therefore not asking that my tech be an RPSGT. I had to fight like h*ll to get a copy of the CD of my sleep study. And finally HAD to have it mailed to a local ACCREDITED sleep specialist by going thru Mayo's Medical Records office. AND the letter from Dr Staats that accompanied the CD to my local sleep doctor SPECIFICALLY asked him to keep the info confidential and to destroy the CD.

Dr Staats was well aware I have COPD and was currently on 2L 02 w/my VPAP Auto at the time. He was aware I saw Mayo's pulmonologist and Staats HAD that information, including the Mayo PFT results, yet not only failed to provide an order for 02 if needed during the study, he failed to include 2L of 02 on my script for pressure change which was printed out, and then handwrote in the addition of 2L of 02 when I questioned him at the time he gave me the script. His dictated results were ONE PARAGRAPH. He tried covering his a** in his office notes (two consults and a phone conversation) and was less than truthful in them as well.

I was started w/an excellent RPSGT when I went to the sleep lab but then was told she wouldn't be doing my titration, that she would be training that night. I won't comment on the titration itself except to say that when 1/2 to 3/4 of the way thru the night I asked for the addition of 02 I was told it was too late in the night to get an order for 02 from the doctor!!!

And, yes, I did write a letter of complaint to the head of the sleep department at Mayo. I do NOT think that my titration at Mayo was indicative of their sleep department overall. I credit the disaster that it was TOTALLY to Dr Staats. He and I did NOT hit it off (to put it mildly) from the get-go. Staats is NOT Mayo calibre. My family and I have been going to Mayo on and off for 50 years and NEVER have I met a Mayo doctor the likes of Staats! NEVER!

As a matter of fact, I have NEVER in my 67 years, and going thru "doctor shopping" after the death of two different, wonderful family doctors, EVER met but one other doctor the likes of Dr Bruce A Staats (and the other one currently actually advertises on local TV for new patients).

Saz RPSGT said:

My point had something to do with what Judy posted. Look for a lab with techs running it that have experience. At the time Stanford was known for having techs that were new and trying to get that "I worked for Stanford" thing going in their favor for future jobs. You can ask that your technician be a RPSGT. You can ask to speak with their scoring techs and ask them any of your concerns.

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Permalink Reply by Sleeping Ugly on December 16, 2009 at 1:53pm

Saz,

A sleep tech at a lab here told me that they don't score RERAs. She said something about the 2008 guidelines mandating certain things, and other things were optional. She made it sound like scoring RERAs is optional. Do the 2008 guidelines mandate scoring RERAs?

Thanks!


Saz RPSGT said:

I think you're correct about Dr. Guilleminault discovering RERAs. He is on the research side though. A couple years ago I know that they were not scoring those. I learned this in a conversation with their lead technician at a conference. When I worked for them on the A.P.P.L.E.S. research study, they didn't score them there either. I'm sure that they are now adhering to the AASM 2008 changes on the sleep lab side of things. Not sure about the sleep research side.

My point had something to do with what Judy posted. Look for a lab with techs running it that have experience. At the time Stanford was known for having techs that were new and trying to get that "I worked for Stanford" thing going in their favor for future jobs. You can ask that your technician be a RPSGT. You can ask to speak with their scoring techs and ask them any of your concerns.

If any is a place to post your story...it is here! :^)

Mercy Sleep Center in Sacramento is awesome!!!! ;^) I may or may not know people that work there.... (shameless plug)

Saz

Sleeping Ugly said:

Saz,

I was thinking of going to Stanford for a sleep study to see if I have UARS. What do you mean they don't score RERAs?! Isn't Dr. Guilleminault the Father of the Modern RERA?!

BTW, do you have an opinion about the Oracle?

(Sometime I must sit down and post my story and see if anyone here can help me. I'm quite discouraged. But that's for another day when I'm only a 20 as opposed to a 40 on the Epworth...)

Thanks!

• ▶ Reply

Permalink Reply by Saz RPSGT on December 17, 2009 at 12:39pm

Nothing to my knowledge is mandated. I think one of our reading physicians is borrowing (long term) our AASM manual, so I can't look it up right now.

Scoring RERAs just makes sense for a better patient outcome. RERAs by definition are awakenings because of breathing reduction. RERAs respond to CPAP. They're the exact same thing as a Hypopnea, but with less of a desaturation.

When there is an arousal while scoring I have to call it something. When there is a clear decrease in breathing and the respiratory belts, like you see with a RERA, it doesn't reflect what actually caused the arousal if I mark it as a "spontaneous arousal" or a "Leg movement with arousal." That situation is exactly what was asked of me at Stanford. When they cease with appropriate pressures of CPAP, then it wasn't a true leg movement with arousal to begin with.

I often review records from other labs and it appears there is no SDB because the AHI and RDI are very low. However, if I look at the section of Leg Movements with arousals, there is an index of 30+. Add CPAP and it goes away.

What's my point to all of this you may be asking. As a patient who is extremely tired all the time, it is a slap in the face to be told that you sleep great at night...no problems....AHI and RDI are really low. A person who has RERAs knows that they absolutely make a difference.

Any sleep lab worth anything should be scoring them. Especially if they know and acknowledge that they exist. Optional? What the hell?!?

Below I have a link to an article I wrote. It has pictures of all kinds of breathing abnormalities. You can compare the RERAs and Hypopneas. Even an untrained eye can see that the brainwaves get much faster (an arousal) and can see that the breathing shallows prior to the arousal. Scoring RERAs is extremely important to getting the correct diagnosis.

http://www.ehow.com/how_5716271_interpret-sleep-study-report.html

Saz

Sleeping Ugly said:

Saz,

A sleep tech at a lab here told me that they don't score RERAs. She said something about the 2008 guidelines mandating certain things, and other things were optional. She made it sound like scoring RERAs is optional. Do the 2008 guidelines mandate scoring RERAs?

Thanks!

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Permalink Reply by RockRpsgt on December 17, 2009 at 4:01pm

RERAs and RDI are optional according AASM scoring manual. Would not have much of a need to score RDI if you were not scoring RERAs. It would not be accurate without them. I agree with you Saz it just makes sense to score everything.

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Permalink Reply by Sleeping Ugly on December 17, 2009 at 4:44pm

I wonder if scoring/not scoring RERAs has anything to do with the sleep clinic's view on esophageal manometry? I got the feeling talking to the tech here that the director of the clinic may be concerned about artifact from the belt/other equipment (they don't use pes). It wouldn't surprise me if Stanford thinks of pes as the gold standard, although I don't know what their views are on the belts, etc.

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Permalink Reply by Saz RPSGT on December 18, 2009 at 12:51pm

To be fair, you're right that an esophageal balloon is the gold standard for detecting RERAS. Pressure transducers like the PTAF have been shown to be statistically just as accurate at detecting RERAs though.

Thermistors.....those can barely detect airflows....don't get me started on them!!! :^)

That wouldn't surprise me about Stanford either. I don't know of too many labs still using that technique though since it's fairly invasive.

Sleeping Ugly said:

I wonder if scoring/not scoring RERAs has anything to do with the sleep clinic's view on esophageal manometry? I got the feeling talking to the tech here that the director of the clinic may be concerned about artifact from the belt/other equipment (they don't use pes). It wouldn't surprise me if Stanford thinks of pes as the gold standard, although I don't know what their views are on the belts, etc.

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Permalink Reply by maxwell on January 30, 2010 at 8:26pm

Here is an interview in which J. Douglas Hudson, MD, Board Certified in both Sleep Medicine and Neurology, describes what a reliable polysomnogram consists of. It is also online here: http://www.reachmd.com/xmsegment.aspx?sid=681

He mentions that a large number of inaccurate or incomplete reports are, currently, being generated by 'sleep study centers' that are set up and run by people who are not Board Certified in several critical fields specialization. He laments an apparent proliferation of unethical 'assessments', resulting in mis-diagnoses and the absence of appropriate treatment. He places emphasis on the professional training and qualification of everyone involved. It would seem important, indeed, to be thorough in investigating any potential sleep study center.

Attachments:

• 681.mp3, 7.4 MB

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Permalink Reply by Judy on January 31, 2010 at 8:50am

Hey, Maxwell, what's this attachment? A 7.4 MB mp3 file? You trying to mermerize us w/some music??? Are you a snake charmer?? *wicked grin*

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