Why Sleep Studies Are Useless To Me

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?

Please note: I reserve the right to delete comments that are offensive or off-topic.

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9 thoughts on “Why Sleep Studies Are Useless To Me

  1. Well, and then there’s the other reason. Because it can confirm if you have sleep apnea :P However, what seems silly to me is that doctors are ordering lab sleep studies rather than home ones. The home ones are substantially cheaper and presumably more comfortable and while they can’t preclude sleep apnea, they can confirm it, possibly avoiding a subsequent study. The home studies are 1/20 the cost of the lab studies however so not only does it avoid a lot of discomfort but it also saves a lot of money. And that’s not trivial, there’s a tendency to want to do split nights as a result of the cost so I actually don’t know what my true AHI is, only a lower bound. However, another interesting point is that you don’t really even need a sleep study. A simple ceph is pretty accurate for determining if you’re likely to have it now or at some point in the future, a point doctors seem to neglect to mention to at risk patients who get a negative diagnosis. For that matter, you can make a pretty good judgement call just by looking at the person.

  2. I’m curious as to whether or not you are receiving RDI and AHI in the reports you are given. Both should be in the report. I often see 20-30 respiratory events per hour due to RERAs/UARS. AHI could be below 5 but the RDI>5, with RDI including apnea, hypopnea and RERAs. That would be clinically significant and should be treated but insurance will not cover it so the patient is stuck with paying OOP for treatment. Uri, home studies are great alternatives but they are not good options for the patient he is talking about. Mild and borderline apnea is almost always significantly underscored due to lack of ‘sleep’ data. During an in-lab study, sleep staging is done with EEG and all wake data is removed from the AHI/RDI calculation which gives a more accurate assessment on the severity of apnea. With no EEG on home test, and poor accuracy with existing devices that estimate when the patient is sleeping, we divide the number of respiratory events over the entire time the device is on. If patient slept for 3 hours but had the device on for 10 hours, they would require 50 apneas or hypopneas (50/10= 5) to be considered mild. In reality, that patient would only need 15 events (15/3=5) to be considered mild. I look at HST devices as a way of confirming apnea, not a way to rule it out. Also, the RERAs he is describing cannot be scored on an HST device without EEG. Respiratory Effort Related Arousals (RERAs) require the EEG because the ‘arousal’ is so short it would not be picked up with any other existing method. This is why in-lab is important for milder patients. Note: Medicare designates AHI for in-lab and RDI for HST. They RDI is for home testing because of the lack of being able to gather accurate ‘sleepy’ time. Interestingly enough, sleep professionals do not have that definition at all. RDI is simply adding RERAs + Apneas + Hypopneas to get a clearly picture of the patient’s breathing. Therefore, you would gather the data Dr. Park is suggesting he does not get from these sleep studies and they would NOT be useless.

  3. I think the greatest problem I have with what we currently call “Sleep Medicine” is that it apparently stagnated about thirty years ago. Here we are all this time later still having extremely expensive medical staff placing leads in a super expensive sleep lab. I suppose that is “golden” alright!

    Do YOU sleep every night in a sleep lab? What happens if you are simply in a different bed for a night? Sleep is upset I would think! How much more if you transport to a sleep lab, get all wired up, and then try to sleep understanding the many hundreds of dollars this is costing and for many that your very life and/or livelihood is on the line!!!

    The setting of the polysomnogram (sleep study / test) should have been changed to the clients bed room at least fifteen years ago. Our technology had been well developed so that it would have supported such a move at that time. By developing self applied sensors and systems the very expensive technical personnel would be much better employed as “fitters and teachers” helping those clients to apply the sensors in the comfort of their own homes.

    When we do develop this then finally we will have some truly scientific data gathered in the “native environment of the sleeper”. Finally we will be enabled to run the tests for several nights and see how sleep varies normally. Then we will really understand how many nights are necessary to understand the true state of the clients sleep.

    Please wake up Sleep Medicine

    As it stands I agree with you that the current test is “nearly useless”. I very much believe that it can be changed to include arousals and tests developed to better define the more subtle problems that develop which do cause harm to sleep and the people who have them.

    May the changes come quickly!

  4. oh wow, this is my biggest pet peeve in sleep medicine. I don’t know what the problem is but I see most sleep studies on people I know, completely miss the diagnosis. I won’t trust any lab but Stanford to get an accurate study. I definitely don’t trust a home test.

    I absolutely agree with your approach Dr. Park, of using alternate data, the patient’s symptoms and anatomy, to guide your treatment. it worked for me. and it would work for everyone else too if doctors were trained to understand this. but most people walk around with narrow jaws and forward head posture but when they go to their doctor, the doc doesn’t even notice that their patient is basically malformed and suffering as a result.

  5. I came across your site by sure accident, I was fascinated. I ‘ve been struggling with gasping during sleep about 80% of the time. I had sleep study last year and the results were ‘normal’. Because I felt this issue causing other health issues to be worse, i was very firm during my follow up appointment that this couldn’t be normal. Sleep doctor was rather frustrated with me, stating it was absolutely not a sleep issue. Left me rather concerned not having any treatment.

    Problem has only continued to get worse and I was fortunate enough to see another sleep Dr. She noted the 47 arousals in an hour and said this was not normal. In addition she noted the enlarged tongue and extra skin in throat. She is requesting another sleep study and feels it is likely I have upper airway resistance. I’m keeping hope that I may finally be able to get some treatment. Thank you for your site, I was just lucky to find it!

  6. in my areas sleep studies report RERAs (respiratory effort related arousals) , the RDI (Respiratory Disturbance Index including RERAs) and EEG arousals. Wouldn’t that be useful data for diagnosing UARS?

  7. Before the days of excessive trolling CPAP forums were useful. As I read those posts which dealt with the ventilatory instability people experience while using CPAP, such as UARS with their RERAs, I noted that they seem to be using a whole lot of air! To find the supply of air from the CPAP insufficient while in bed was a wonder indeed.

    I think I now understand why.

    So at the base of the brain resides the “Circle of Willis” whose posterior portion is the “Posterior Communicating Arteries” such being what provides the flow of blood to the base of the brain from the internal carotid arteries.

    I believe it is of extreme interest here that the Posterior Communicating Arteries have been found (by autopsy) to be absent or insufficient in half of those examined!

    The only other supply of blood to the base of the brain (basilar artery) is through the vertebral arteries which enter the the vertebrae at about C5 and exit at the axis going to the posterior of the basilar artery.

    Through my own experience I very well know that letting my head drop forward (forward head posture) results in increased breathing and heart rate while simply putting it back on the top of my head with a neutral spine stabilizes breathing and heart rate. Consistently! If my posterior communicating arteries are insufficient and there is some inflammation in the area of my neck vertebrae it makes sense to me that changing posture would facilitate a better flow of blood to the base of the brain thus eliminating the signals emanating from there which were a desperate effort to supply the essential blood to the base of the brain.

    In my little “blog to be” you can read about the neck exercises I use even today to make a healthier neck vertebrae area. I have made many dietary changes for less inflammation and am now reading Gundry’s “The Plant Paradox” which I am suspicious will supply even better dietary wisdom.

    I believe that while there may be resistance in the upper airway UARS is more likely originating from a lack of blood to the base of the brain.