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JoeBorelli

JoeBorelli
Joined Mar 2015
JoeBorelli
Joined Mar 2015

The first physician that evaluated me, on first meeting me, said "You don't have sleep apnea." I didn't fit the stereotype of an obese, middle-aged male. I had a sleep study in his accredited lab and the results were "normal." In his subsequent letter to me, he said "Joe, you need to get a good night's sleep..." and prescribed a controversial (80% of sleep medicine physicians do not recommend its use) anti-depressant. As a physician, I knew this was a typical response to placate a patient. It's the same reason antibiotics are over-prescribed. Otherwise, patients feel that their physician did nothing to help them. I never fill the prescription.

Next, I went to a local university medical center, after two more years of suffering and progressive cognitive decline. When the sleep specialist examined me, she was certain that I had REM-sleep-related OSA and guaranteed my sleep study would bear this out. Unfortunately, this study showed my AHI was only 4.8 (which doesn't meet the arbitrary diagnostic criterion of 5.0). Yet she still ordered a titration study, showing I needed a CPAP pressure of 5.0 cm of water. The latter treatment made me worse!

What both of these sleep medicine institutions failed to due was properly evaluate me for AROUSALS via the EEG. This takes a great deal of skill and very careful, time-consuming review of the PSM (polysomnogram) data. The hypopneas and associated arousals are subtle but very real and devastating to the patient. Once I finally traveled across the country to Stanford (after contemplating suicide – I had literally become a basket case, unable to dress myself or remember any recent events), I was ultimately diagnosed with UARS (upper airway resistance syndrome) with an AHI of 28 and a titration pressure of 13 cm of water. Thus, the first two sleep studies were falsely negative. At least the second sleep physician was convinced I had OSA based on my history, but her treatment (with an inadequate pressure) was intolerable. Imagine air blowing into your airway at a pressure too low to open it. That worsened my sleep and exacerbated my symptoms. They blew me off as non-compliant and refused to see me again!

What I have learned from my experiences is the following:

  1. There are no valid gender or body habitus stereotypes – ANYONE can have sleep disordered breathing, including young, thin females (as well as children). It's more a matter of upper airway structural geometry than body type.
  2. UARS (hypopnea and arousals without complete obstruction) is equally damaging clinically, may be MORE COMMON than classic OSA and is under-diagnosed at alarming levels. Most labs are either ignorant or fail to take the time to study the PSM adequately to detect UARS.
  3. It is VERY EASY to diagnose OSA/UARS from history alone. I have diagnosed dozens of friends, acquaintances and patients in less than 5 minutes by asking a few key questions. I have encouraged all of them to seek formal diagnosis at Stanford. Others I have place on APAP (auto-titrating CPAP) empirically with excellent results. In one example of the latter, a 25-year-old, thin female slept 12 hours on APAP on the first night and felt refreshed for the first time in memory. A week later she stopped taking her prescription hypnotic. She's been 100% compliant for over 6 months now and is a changed woman.
  4. We now know that up to 90% of people with chronic insomnia have un-diagnosed OSA/UARS. We need to identify these folks early (in their 20's, 30's and 40's) and get them on CPAP/APAP before any damage (to the brain, autonomic nervous system, cardiovascular system, endocrine organs, etc.) is done. Mass screening is likely where we will end up in 5 years, once the cost of detecting UARS comes down.
  5. Children present differently (as did I) with SDB. They may have "essential" hypertension (as in my case at age 10), learning disorders, behavioral disorders or ADD. All children with any of these presentations should be evaluated for OSA/UARS.