Generally, a sleep study is a term to describe any test for diagnosing and/or treating sleep problems.
These include the portable or home sleep test (HSAT), the nocturnal polysomnogram (NPSG), the split night study, the PAP titration, and daytime studies that include the Maintenance of Sleep Latency Test (MSLT) and the Maintenance of Wakefulness Test (MWT).
What are the main sleep tests or studies?
There is more than one kind of sleep test. You cannot assume that the one your doctor orders for you will be the same one ordered for a friend or relative. Often, it’s the patient’s insurance carrier which has a shaping influence over sleep testing protocols, as well.
Home Sleep Apnea Test
A home sleep test (HSAT) is typically prescribed when your doctor suspects you might have a sleep breathing disorder. You will be sent home to sleep that night with a kit composed of various sensors, which usually include:
- a belt to measure respiratory “effort”
- a finger probe to measure heart rate and blood oxygen levels
- a cannula sensor used to measure airflow
When you pick up the test, your doctor or sleep technologist should show you how everything is attached and how the test is turned on and off. There should also be written and/or video instructions contained with the test kit, in case you forget.
The HSAT is often required by insurance payers to screen patients for the likelihood of sleep apnea before they come in for an overnight test as the HSAT is considerably less expensive.
The test is fairly simple and mostly accurate enough for the purposes of detecting the presence of sleep disordered breathing.
It is also, for some patients, a more desirable option as it is conducted in the privacy and comfort of the patient’s home.
In October 2017, the curator of SHC will post a video demonstrating how to perform a home sleep test to show just how easy it is. Stay tuned!
Generally you return your HSAT hardware on the morning after the test and follow up within a week with your sleep physician to discuss results.
An HSAT may not work the first time, and you may be asked to do the test again. You will not be charged for any tests in the case of a hardware failure.
Sometimes the results of an HSAT will indicate that you need to go in for an overnight sleep study in the sleep clinic because the results were either:
a/inconclusive, but strongly suggestive of a sleep disorder
b/conclusive (a sleep disorder is or isn’t present)
Inconclusive testing means there’s a likelihood that additional tests may be needed to uncover a different sleep problem, or the results were borderline for a sleep breathing disorder.
Conclusive outcomes may still require further studies to identify appropriate therapy settings before treatment can be started.
If you are diagnosed with sleep apnea based on an HSAT, you will meet with a durable medical equipment (DME) provider to receive your sleep apnea treatment. This is usually an automatic positive airway pressure (Auto-PAP) machine which comes with a preset pressure range.
When HSAT test results are negative for sleep disordered breathing, this doesn’t necessarily mean the patient doesn’t have a sleep disorder. Many other sleep disorders besides sleep apnea can cause excessive daytime sleepiness or sleeplessness at night, so a followup study in a lab setting may still be required.
A nocturnal polysomnogram (or NPSG) is a diagnostic test conducted in a sleep laboratory which measures physiological data occurring in patients while they sleep.
The data come from various kinds of sensors attached to different parts of the body: the scalp, the chin, the brow and cheek, the throat, the nose and mouth, the legs, the chest, and the abdomen.
About the sensors
- Sensors on the scalp measure changes in brain wave (EEG) architecture, which show changes in sleep stages. These can also capture unusual brainwave activity that might be related to seizure disorders or epilepsy.
- Chin sensors (EMG) indicate when patients are awake, tense, lightly asleep, or in REM sleep.
- Brow and cheek sensors record different kinds of eye movements (EOG) during both sleep and wake stages.
- The throat sensor records snoring activity.
- The nose and mouth sensors measure incoming and outgoing airflow.
- Leg sensors (EMG) indicate muscle activity in the limbs that can be caused by arousals, movement disorders, and other physiological disturbances.
- Electrode patches on the chest record ECG patterns (heart rhythms), and belts around the chest and waist show evidence of respiratory effort (or lack thereof), which helps to identify breathing disorders of sleep.
- An additional device, the pulse oximeter, is clipped to the patient’s fingertip; this device measures both the heart rate and the amount of oxygen saturating the blood, which lets the interpreting physician know just how much (or how little) oxygen a patient is circulating while they sleep.
Once the patient is hooked up to these sensors, they are asked to sleep in a technologically equipped bedroom and monitored via video and audio equipment for the night.
The laboratory technologist collects data which, when scored and interpreted by a sleep physician, can provide answers to explain certain kinds of health concerns, such as excessive daytime sleepiness, morning headaches, low blood oxygen at night, or high blood pressure.
Generally these tests are administered during the evening. However, some patients who work overnight shifts may be scheduled for attended polysomnograhy during the day, when they typically sleep.
Split night study
This test is performed for some patients for whom a diagnosis of Obstructive Sleep Apnea (OSA) or upper airway resistance is highly likely. This is often determined by a pulmonologist who specializes in heart and lung disorders.
A split night study starts out like the NPSG; the patient is prepared in the same way and the same signals are attended during the test. However, respiratory events are a chief focus of observation in this test.
Respiratory events are moments during sleep when the airway is partially or completely obstructed for at least ten seconds, or when arousals occur due to airway resistance, such as in the case of heavy snoring.
Respiratory events in a split night study are tallied over the first third of the test and, if the patient has experienced enough to meet lab protocol, they are given positive airway pressure (PAP) therapy to help eliminate these events.
This study involves the use of a positive airway pressure device and mask to identify the best therapeutic measurement of air pressure for people with OSA.
Positive airway pressure is essentially delivery of very light puffs of air to the patient’s upper airway in order to assist the patient in completing inhalation and exhalation, both which may be obstructed due to confirmed issues of blockage in the upper airway.
The patient is acclimated to the mask by wearing it before the titration using very light pressure. Then they are hooked up like they would be in an NPSG. However, in the case of a PAP titration, they start their study using PAP therapy.
As they sleep, the technologist remotely and digitally adjusts the therapeutic level of positive pressure feeding through the device and mask, as well as humidity and pressure support for exhalation, until they determine the pressure which most benefits the patient is the most comfortable for them.
Maintenance of Sleep Latency Test
This test helps to identify hypersomnia condition, such as Idiopathic Hypersomnia, Narcolepsy with or without Cataplexy, and Klein-Levin Syndrome (“Sleeping Beauty” disorder).
The MSLT is usually performed on patients on the morning following an NPSG. These are people who are known to be excessively sleepy during the day but who have been determined not to have sleep apnea.
Some of their overnight sensors are removed while others are left on for up to 5 tests performed about 2 hours apart during the day. These nap periods allow the technologist to record their brain wave patterns at those times, which can reveal conditions of hypersomnia.
Maintenance of Wakefulness Test
This test is often used for commercial truck drivers, airline pilots, bus drivers, and other operators of public or commercial vehicles or industrial equipment—anyone who may be at risk for falling asleep at the wheel or while operating machinery.
For these workers, the risk of drowsy driving is too great to ignore any problems with untreated sleep disorders, especially sleep apnea, which can be more common among this population.
A patient undergoes an MWT by being hooked up to specific set of sensors, then sitting in a dark room for a certain period of time during the day. This objectively determines how well they can stay awake in low stimulus conditions.
Will insurance cover my sleep study?
Generally, sleep studies are considered medically necessary because they are critical to identifying underlying sleep disorders, especially those related to disordered breathing.
Fortunately, most sleep disorders are treatable and therapies are also generally covered by most insurance companies.
Different insurance companies cover different kinds of tests and durable medical equipment (DME) related to sleep testing, so it’s best to consult your insurance company to see what they will reimburse. (Your doctor should also be able to help you with this.)
You will likely need to be referred for a test and might need to have your studies and equipment pre-approved by your insurance company before taking a test. Often a doctor’s choices for treatment will be limited by what your insurance is willing to reimburse.
It is advised that all patients look at their insurer’s policies regarding failed or incomplete tests. Generally, patients aren’t charged for tests that have failed mechanically.
If you decide in the middle of a test that you no longer want to participate
If a patient leaves a study in progress, this is considered “against medical advice” (AMA). You will need to sign a form (called an AMA) stating you understand you are leaving against medical advice.
Your insurance company may or may not reimburse in this case, and you could be held responsible for payment—partially or completely—for this expensive test.
How do I prepare for a sleep study before I get to the lab?
Usually the lab will give you specific instructions, so please consult them first. In their absence, here are some general guidelines.
To Do List for a Sleep Study
- Come in with clean, dry hair
- Remove makeup
- Eat your evening meal 2 or more hours before coming to the lab
- Remove dark nail polish, if possible, as it might interfere with function of the finger probe
- Avoid alcoholic or caffeinated beverages or foods 5 or more hours before coming to the lab
- Prepare to be told you cannot smoke at least 30 minutes before your study starts (which includes vaping)
- Take your usual medications, but do not take any sleep aids until you’ve alerted your technologist to the fact you are taking them; it is important to start your study awake!
- Manage your diabetes medications as usual
- Expect to start your sleep study with all electronics—including the TV, cellphone, and radio—turned off, even if it’s normal for you to have these on at bedtime
Packing List for a Sleep Study
- Clothes to sleep in (do not bring lingerie); pajamas, nightshirts, t-shirts, and shorts are all acceptable. Nude sleeping is not permitted in the sleep lab and hospital gowns may or may not be available
- Slippers to walk in, and a robe; some labs will set up patients in their rooms, while others will set them up in separate locations inside the lab where other patients might see them
- Comfort items like a favorite pillow, blanket, or stuffed animal
- Your evening medications (note: technologists are not permitted to administer medications). These could include your usual prescriptions as well as over-the-counter pain relievers, decongestants, nose sprays, antacids, heartburn medications, and the like
- A white noise machine, if this is helpful for you (some labs have these available)
- Your usual personal care items like shampoo, conditioner, soap, toothpaste, toothbrush, deodorant, etc. Though many sleep labs are set up to resemble hotel rooms, they are still medical facilities and do not always provide these personal care items
- If you are diabetic, having some snacks on hand is okay if that will help you regulate your blood sugar through the night
- Most labs have overhead or standing fans to help keep rooms cool for patients who need them
List of Things NOT TO DO OR PACK for my sleep study
- Anything with a strong fragrance; most labs are fragrance-free environments
- Fast food or other carry-out food items that have a strong aroma
- Pets (service animals are an exception)
- Loved ones may come with you to the lab to help you get comfortable, but they cannot typically stay the night unless they are pre-approved as caregivers; patients under the age of 18 must be accompanied by a parent or guardian who will be expected to stay overnight
- Electronics like laptops, cell phones, and handheld gaming devices; if you do bring them with you, please be prepared to turn them off completely stash them for the night. Electronics can cause problems with sleep onset as well as disrupt electrical signal data collection
- Alarm clocks; you will be woken by the technologist in the morning upon completion of the study
- Jewelry can interfere with electrical signal data collection and is best left at home
What medications can I take before my sleep study?
Unless advised differently by your physician, take your normal medications.
If you have sleeping pills, hold off taking them until you have had a discussion with your technologist, as they will direct you to the proper time to take them.
However, the lab will not necessarily have these on hand, and sleep technologists are not nurses, so they cannot legally dispense medication of any kind, even aspirin or antacids, so please make sure and bring your favorites in case you need them.
How will the technologist prepare me for a sleep study once I’m at the lab?
Depending upon the nature of your visit, the technologist will prepare you for your study in various ways.
Typically, preparation will include application of scalp and body sensors and trying out several kinds of PAP masks to find the one that fits you best and is most comfortable for you, in the event you will need it.
The technologist is also a sleep educator who is trained to answer all your questions about the test, so feel free to ask questions of them or express any fears or concerns you may have.
At “Lights Out,” the study begins, and your sleep technologist will work with you to perform calibrations. These include little exercises you complete at their instruction, such as blinking your eyes or pointing your toes, so they can capture a digital record of the baseline measurements related to each of the sensors you have attached to your scalp and body.
Each patient displays different variations on these signals (size, shape, speed), so these calibrations come in very handy for the scoring technologist and physician later when they prepare to score and interpret your study after you’ve gone home.
Why do the technologists have to audio and video record my study?
Often the sensors attached to the patient show unusual signals. Using video and audio feeds live helps the technologist to determine whether the unusual signals are due to sensor malfunction or to symptoms caused by sleep disorders or harmless patient movements.
Some kinds of sleep disorders, those involving unusual movement or vocalization, require audio-visual records to confirm diagnostically.
Audio-video streaming also helps the sleep technologist and patient to best communicate with each other as they are in separate spaces for most of the test.
Physicians who have questions about certain aspects of the study may call up both the audio and video recordings to see what happened in those moments during the study, long after the study has been completed.
Finally, because of the somewhat intimate nature of the sleep test, an audio-video recording offers both the patient and the technologist legal protection against any misunderstandings which might occur while the technologist is in the room with the patient at night.
Conversations and activities are recorded in order to provide some objective data when such disagreements arise in these rare occasions.
Snoring, catathrenia, and sleep talking can be confirmed through audio feed.
Generally, the image of the patient, which is black and white, is kept in a small window inside the upper corner of the computer monitor screen in the lab. The technologist will refer to it to examine and corroborate patterns coming from the signals without having to disturb the patient.
Body position, an important part of data collection, can be confirmed via video feed. So can unusual movements that may indicate rare sleep disorders.
What happens if I have trouble sleeping during my sleep study? Won’t it ruin my test?
Most patients are expected to be a little on edge at first; this is normal. Your best approach is to try to sleep as well as you can and try not to worry about your sleep quality or quantity. The vast majority of sleep study patients do, in fact, sleep enough during a study to provide meaningful results.
It may help to know that the technologist runs the study in such a way as to account for so-called “first night effect,” which impacts nervous patients who can’t sleep initially. Very rarely does anxiety at the beginning of the night impact the overall efficacy of the test.
What are the technologists doing while I’m asleep?
They are not sleeping! They are, in fact, extremely busy, especially if they have multiple patients. They:
- monitor the data collected by the signals attached to your scalp and body
- write regular reports and tag specific data inside the study as it happens so the scoring technologist and physician can interpret the study later
- adjust PAP pressures and settings or oxygen settings, as needed
- fix or replace any sensors that might have fallen off or might otherwise not be working properly in order to collect the clearest data
- assist you with getting to the bathroom in the middle of the night
- help you with comfort issues (more pillows, cooling fans, noise machines)
- update medical records related to your study
- prepare your followup paperwork
What time will I get up?
Generally speaking, patients are woken up by the technologist between 5 and 6am.
Following “Lights On,” they will calibrate your signals, unhook you from all the sensors, go over your followup paperwork with you, and offer any assistance you need in getting ready in the morning.
This usually takes less than 30 minutes, after which you are free to clean up.
Some labs offer breakfast foods; hospital-based labs often hand out coupons for free breakfast in the cafeteria.
Please don’t linger
The technologist you have worked with at the beginning of your study will most likely be the same technologist who will unhook you.
At the end of your test, they will be busy cleaning and sterilizing equipment, assembling packets of information for you to take home, updating medical records, and preparing your data for scoring by another tech. In some labs, they are also tasked with changing linens and towels and restocking the bedrooms and bathrooms.
Sleep lab techs generally work 12-13 hours overnight, then go home, sleep during the day, and return to work the next night.
As a courtesy, it is helpful as a patient to not linger after your study is completed and you have cleaned up.
If you are waiting for a ride, it is better to do so in the waiting room so the technologist can complete their shift. They are unable to leave until their patients have vacated the lab or someone else has arrived to relieve them, which may or may not correspond with the end of their shift.
How soon will I find out my sleep study results?
Most labs will get back to you within 2 weeks. Your sleep technologist should give you information about the process following your study before you leave the lab.
Note: Technologists are not physicians and are, therefore, not qualified to diagnose patients. The technologist cannot discuss your test results the following morning, as a typical test includes about 800 pages of raw data that still require scoring before the physician can interpret the results.
If you have any concerns, your technologist can take notes which can be forwarded on to your physician with your study.
Will I have to have more than one sleep study?
It depends upon what your particular sleep issues are. Some sleep disorders are adequately diagnosed after a single study, while other sleep disorders require different tests on different nights and sometimes even during the day to get at the root cause of the problems.
There is no typical procedure; each test for each patient is determined by their unique needs.