With the development of the overnight sleep study by sleep researchers, sleep medicine was born in the mid 1900s. The term polysomnogram refers to multiple variables that are measured during sleep. Determining sleep stages by analyzing brain waves and eye movements was a monumental step for medicine in general. Tomes of research and incredible insights have been discovered through what’s found during sleep studies. So why am I saying that sleep studies are useless?
Take for example, Jenny, who is a young, thin woman to came to see me for her severe fatigue, anxiety, and headaches. She also has trouble staying asleep, waking up every 2 hours to go to the bathroom. Her father has a history of sleep apnea, so her sleep physician ordered a sleep study for Jenny, which came back as being normal. Her AHI (apnea hypopnea index) was 0.5, which was well below a level of 5 that’s needed for a sleep apnea diagnosis. The final interpretation stated that there was no evidence of obstructive sleep apnea or sleep-related breathing disorders. She was eventually offered treatment for insomnia.
When I saw Jenny, it was clear that she had a major sleep-breathing problem. She had a tiny mouth, with severe crowding of her upper airway. She eventually underwent nasal surgery to address her nasal congestion, during which time endoscopy under anesthesia showed severe tongue collapse with each breath in. The space behind her tongue was no more than 1-2 mm, and obstructed completely with each inhalation. Furthermore, her epiglottis, a cartilaginous flap that sits behind the tongue above the voice-box, fell back completely with each breath in.
It’s now considered standard of care to undergo a sleep study if you may be at risk for obstructive sleep apnea. There are very specific criteria to qualify for a sleep apnea diagnosis. As mentioned previously, you need to have at least 5 apneas or hypopnea every hour on average to be eligible for a sleep apnea diagnosis. Each episode has to last more than 10 seconds. Jenny’s problem was that when she obstructed, she woke up too quickly.
I see patients daily who don’t officially meet the formal criteria for sleep apnea based on sleep studies, but stop breathing 20 to 30 times every hour. Oftentimes, these more subtle obstructions don’t lead to any drops in oxygen levels, but can cause repeated partial arousals from deep to light sleep. Imagine never being able to stay in deep sleep for more than 1-2 minutes the entire night.
The main reason why I still order sleep studies is because you need a sleep apnea diagnosis for insurance carriers to cover any type of treatment. If you come in below 5, you’re out of luck, no matter how many times you stop breathing. Regardless of whether or not you have a formal diagnosis of sleep apnea, my philosophy is to treat the patient and the anatomy, not the numbers. In an upcoming post, I will describe my protocol for treating people who are in this dilemma, called upper airway resistance syndrome.
If you can’t sleep and were told you don’t have sleep apnea after testing, what did your sleep doctor recommend?