Sleep apnea and immediate action

N

Notsleepy

Guest
So, fun, I was just diagnosed with mild sleep apnea: 8.4 events per hour, 89% minimum O2. Nothing too terrible but enough that I need to be on treatment. I'm flying on a Class III. This was a bit unexpected, as I'm in none of the high risk categories listed by the FAA. I'm slim and healthy. I was not required to take the test by the FAA. My wife wanted me checked out, so I obliged.

So...I know that if an AME saw this, he could not issue without a handful of items. All of them can be procured, as I'm going on immediate recorded CPAP treatment. But...am I at any risk of losing my medical or pilot action if I continue to fly? Reasonably, my self-assessment is that I'm still fit to fly, just as it was before the diagnosis. I think that means I"m still good to go and I need to cross that bridge when my medical comes up in March.

That said, if I went to get a medical today, there would be paperwork and a needed SI for Class III. (Aaarrrgh. Why is this an SI issue instead of an AME checkable issue?) I believe, if I read correctly, I would still get an immediate issuance, just with more to do afterward. Or I could go BasicMed and avoid the SI. (Maybe I can figure out what is causing the OSA and use lifestyle changes to wipe it out? Avoid the blemish of the SI?)

Basically, I'm asking if I'm still good to fly until my medical runs out in March. However, I'm open to hearing stories of OSA SI experiences, if you want to relate.
 
I don't know that an SI constitutes a "blemish" unless you are planning to fly professionally as a career. But yes, the FAA documentation requirements for OSA are reported by some to be rather burdensome, though several folks on here with OSA seem to consider the burden manageable.

I don't know whether the dx is immediately grounding on a 3rd class; hopefully one of our resident difficult-case AMEs will weigh in on your question about continuing to fly on your current medical. BasicMed is definitely an option, since OSA is not one of the conditions requiring a one-time SI.
 
suggest a dedicated sleep apnea (sub?) forum on this site
 
azure said:
I don't know that an SI constitutes a "blemish" unless you are planning to fly professionally as a career. But yes, the FAA documentation requirements for OSA are reported by some to be rather burdensome, though several folks on here with OSA seem to consider the burden manageable.

I don't know whether the dx is immediately grounding on a 3rd class; hopefully one of our resident difficult-case AMEs will weigh in on your question about continuing to fly on your current medical. BasicMed is definitely an option, since OSA is not one of the conditions requiring a one-time SI.
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BasicMed is an option, but if that were the route and Class III is not good, I'd still have to stop flying now until I got the BasicMed done. Haven't even opened the subject with my doctor, so I'd imagine it would be a few weeks to get that paperwork done.

As things go, this is mostly an annoyance and I realize that. Still, I'm going to try to minimize the annoyance. :)
 
some folks work night shifts period, others 3 shifts & 24/7
 
Find an AME that knows how to handle it and he won't defer it if he knows what he's doing. Mine issued the medical himself at the time and just sent in my info. Signed letter from the sleep doc saying the machine was doing it's job along with the year printout and another doc signed you can get at the FAA site. Wasn't a problem at all.
 
Notsleepy said:
BasicMed is an option, but if that were the route and Class III is not good, I'd still have to stop flying now until I got the BasicMed done. Haven't even opened the subject with my doctor, so I'd imagine it would be a few weeks to get that paperwork done.

As things go, this is mostly an annoyance and I realize that. Still, I'm going to try to minimize the annoyance. :)
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Why would it take weeks? Do the online stuff today, go to a Doc in the Box Monday, and be done with it.
 
Stuart Fraley said:
Why would it take weeks? Do the online stuff today, go to a Doc in the Box Monday, and be done with it.
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This. Though a "doc in the box" might want some additional testing or documentation to cover his a$$, so you might be better off sticking with your current doc, assuming he will do the BasicMed exam (some AMEs will do it, some won't). Even so, I can't see why it would take weeks. You can have the exam, get the signoff, then take the online course and get everything squared away the same day. The only waiting I can see you might have to do is for the appointment.

Edit: doing the online course today THEN going to the doc is possible, but you will have to go back after the exam to put in the doctor's ID number to finish the process.
 
8.4 is pretty low. 5 an hour is considered normal from what I read on the interwebs. Some studies show that treating mild sleep apnea is not required or desireable. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564770/ If you are already fit and such this may not be true for you. Keep in mind you will have bad nights and good nights depending on if you are congested or your sleep position. I get more events the more I sleep on my back even with my machine. I recently went to one pillow instead of two because of stiff neck and my AHI was slightly higher due to my body position. I would fall in the middle of the moderate OSA catagory when I was tested and I never had day time sleepiness either.

I went Basic Med for a few reasons the sleep apnea SI was for sure one. I use my machine every night but having to make sure you get 6 hours every night can be a pain. Occasionally I would wake up just because I couldn't sleep and would have to lay there for an hour to get the 6 hours in. Then there is the paperwork not only do you have to do the paperwork but you have to do it every year not every 2. Now I do my annual physical with my doc and when I need it he does the Basic Med at the same time. Saves me a bunch of money and time.
 
Another BasicMed success possibility.

And yet, people whined about it when it came out (scratched head).

Any doctor will do it. I’ve asked 15 now if they’d be willing and all have said yes (I used the first one myself). Not a single no. People who tell you it is difficult to find a doctor willing to do it are lying to you.
 
SkyHog said:
Another BasicMed success possibility.

And yet, people whined about it when it came out (scratched head).

Any doctor will do it. I’ve asked 15 now if they’d be willing and all have said yes (I used the first one myself). Not a single no. People who tell you it is difficult to find a doctor willing to do it are lying to you.
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There's no reason to assume that everyone's experience is the same as yours. The first doctor I asked said no. The second one said yes.
 
SkyHog said:
Another BasicMed success possibility.

And yet, people whined about it when it came out (scratched head).

Any doctor will do it. I’ve asked 15 now if they’d be willing and all have said yes (I used the first one myself). Not a single no. People who tell you it is difficult to find a doctor willing to do it are lying to you.
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Several people have posted that they have had trouble finding a doctor to do it. Do you really think they are all lying?

Dr. Bruce has said, I think, that he couldn't afford the increase in insurance premiums. My understanding is that many AMEs have come to the same conclusion. (Of course, there are still many who will do it.)

That said, I agree: this appears to be a good candidate for BasicMed.
 
I don't understand the basic med route unless it doesn't matter to him. It's 'just' sleep apnea and an SI. I had no problem with mine at all and hold a 2nd class medical.
 
2 parts to the OP's question:

Is he grounded immediately, or can he fly until his next medical?

How "painful" is the SI?

I don't know the answer to #1.

#2, though, is something a lot of us have been dealing with for many years. The first SI might be a hassle, but that depends on your AME. After that, simply print a copy of your CPAP report and get a status report from your doc, turn it in once a year to FAA or your AME to get a renewal right away (a couple weeks if you go FAA, in office if you go AME.) Or go Basic Med and don't worry about it.
 
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Matthew said:
2 parts to the OP's question:

Is he grounded immediately, or can he fly until his next medical?

...
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This, yeah, I haven't heard anyone opine on that. That's really the one that's burning. Everything else I can deal with. But I want to know if I can keep flying for now.
 
Notsleepy said:
This, yeah, I haven't heard anyone opine on that. That's really the one that's burning. Everything else I can deal with. But I want to know if I can keep flying for now.
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That's the big question since you don't yet have any date on how the machine is working for you.
 
Notsleepy said:
This, yeah, I haven't heard anyone opine on that.
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"61.53 Prohibition on operations during medical deficiency.
(a) Operations that require a medical certificate. Except as provided for in paragraph (b) of this section, no person who holds a medical certificate issued under part 67 of this chapter may act as pilot in command, or in any other capacity as a required pilot flight crewmember, while that person:
(1) Knows or has reason to know of any medical condition that would make the person unable to meet the requirements for the medical certificate necessary for the pilot operation"

If Sleep Apenea requires a special issue, then it makes a person "unable to meet the requirements for the medical certificate necessary for the pilot operation".

If you were flying under the Sport Pilot rules, then the standard would be "any medical condition that would make the person unable to operate the aircraft in a safe manner.", but, if you are driving a 172, then it doesn't matter if you can or can't operate safely - what matters is if you meet the requirements for a medical certificate or not.
 
Thread drift coming...wonder how the FAA is viewing the Inspire, inplanted hypoglossal nerve stimulator?? This procedure is slowing gaining popularity in part due to people not wanting to wear the “iron lung”.
 
Capt. Geoffrey Thorpe said:
"61.53 Prohibition on operations during medical deficiency.
(a) Operations that require a medical certificate. Except as provided for in paragraph (b) of this section, no person who holds a medical certificate issued under part 67 of this chapter may act as pilot in command, or in any other capacity as a required pilot flight crewmember, while that person:
(1) Knows or has reason to know of any medical condition that would make the person unable to meet the requirements for the medical certificate necessary for the pilot operation"

If Sleep Apenea requires a special issue, then it makes a person "unable to meet the requirements for the medical certificate necessary for the pilot operation".

If you were flying under the Sport Pilot rules, then the standard would be "any medical condition that would make the person unable to operate the aircraft in a safe manner.", but, if you are driving a 172, then it doesn't matter if you can or can't operate safely - what matters is if you meet the requirements for a medical certificate or not.
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How does Basic Medical work here? The OP doesn't have an SI, yet, so could he get a Basic Med now, then get the SI paperwork started and fly anyway? (edit: The SI would only be necessary if the OP wanted to maintain a class III.)

In my case, I had the OSA diagnosis before I started flying, so I didn't end up in this spot. I don't remember if I've heard a Doc Chien ruling on, "Can I fly on a Class III during the time between my OSA diagnosis and my SI?"
 
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He could get BasicMed now and be good to fly for the next 4 years. End of story. No SI, no FAA.

I am not sure I would qualify this diagnosis as a medical deficiency requiring grounding. The FAA allows issuance of a 3rd class by the AME with a diagnosis of OSA but requires followup reporting - it's a Group 2 risk class. If the pilot did nothing until their next medical, they would walk out of the medical with an issuance and a requirement to follow up. It seems silly then to require grounding now when it wouldn't be required at a medical exam. My call is to initiate what treatment is necessary and report at your next medical. Expect that if you are in the apnea realm, you will be required to use a CPAP and to report compliance at a certain level with it.

Personally, I would be looking for a second opinion, there is apparently a frequent diagnosis failure for mild cases based on event counts.

I have also personally found that there are certain foods which cause inflammation that can bring on more interrupted sleep. Avoid carbs for a few days and I bet you are a much better sleeper.
 
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bflynn said:
I am not sure I would qualify this diagnosis as a medical deficiency requiring grounding. The FAA allows issuance of a 3rd class by the AME with a diagnosis of OSA but requires followup reporting - it's a Group 2 risk class. If the pilot did nothing until their next medical, they would walk out of the medical with an issuance and a requirement to follow up. It seems silly then to require grounding now when it wouldn't be required at a medical exam. My call is to initiate what treatment is necessary and report at your next medical. Expect that if you are in the apnea realm, you will be required to use a CPAP and to report compliance at a certain level with it.
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This sounds reasonable, but I would wait for Bruce's input before flying again, if I was the OP. In similar cases Bruce has said that it depends on whether your certificate level requires being tested on Part 67 (basically, a CFI or ATP), but in this case I really have no idea.

But yes, he could go BasicMed now and continue to fly once he has the signoff/online course checked off. No SI needed unless there is something else in his history.
 
This machine is infernal. I can't sleep with the damn thing tickling my nose every few seconds. I'm cranky, tired, and miserable. It makes my fingers and toes tingle. It makes me take fast, short breaths that are utterly unnatural. How long does it take to get used to this torturous device? I'm definitely in far worse condition now than before.
 
Notsleepy said:
This machine is infernal. I can't sleep with the damn thing tickling my nose every few seconds. I'm cranky, tired, and miserable. It makes my fingers and toes tingle. It makes me take fast, short breaths that are utterly unnatural. How long does it take to get used to this torturous device? I'm definitely in far worse condition now than before.
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What is your therapy pressure?

If it's on the high side, maybe >10 cm H2O, there are some things you can play with on your own under the "comfort settings" menus. Unless you have what's known as a "brick", there are ways to change a few things without getting into the therapy areas that would change your prescription settings.

You can enable a ramp - this will start it at a set pressure of your choosing, then ramp it up to your therapy pressure over 20-40 minutes to allow you a chance to fall asleep at the lower pressure.

You can enable an exhaust relief - this sets a lower pressure during your exhales. The machine will sense when you exhale, then lower the pressure by some adjustable amount.

It's been a long time, but I think it took me 4-6 weeks to fully acclimate.

The biggest problem was getting used to the mask itself, not the air pressures. If you are using a DME, don't be shy about going back and trying a different mask. Sometimes what they send you home with just doesn't work for you.
 
Matthew said:
What is your therapy pressure?

If it's on the high side, maybe >10 cm H2O, there are some things you can play with on your own under the "comfort settings" menus. Unless you have what's known as a "brick", there are ways to change a few things without getting into the therapy areas that would change your prescription settings.

You can enable a ramp - this will start it at a set pressure of your choosing, then ramp it up to your therapy pressure over 20-40 minutes to allow you a chance to fall asleep at the lower pressure.

You can enable an exhaust relief - this sets a lower pressure during your exhales. The machine will sense when you exhale, then lower the pressure by some adjustable amount.

It's been a long time, but I think it took me 4-6 weeks to fully acclimate.

The biggest problem was getting used to the mask itself, not the air pressures. If you are using a DME, don't be shy about going back and trying a different mask. Sometimes what they send you home with just doesn't work for you.
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The pressure isn't high. Between 4 and 6 and its being remotely adjusted this first week by the tech. It has a cell connection and they're monitoring me this week. I only have one night where I managed to wear it all night and it was one of the most miserable experiences I've had in a while. Every other night I've lost it and ripped it off at around three hours. I'm definitely going BasicMed for now...I don't know if I can be 6 hour compliant in the short term. I haven't bought my long-term machine yet...this one is a loaner for trial. (Retail price: $2200. Holy hell. Glad I have an 80% DME coverage.) Dunno yet if I'll buy this exact model.

I believe it already ramps. It does have both a diffuser at the end and it stops pressure on the exhale. But it's not long enough. Before I'm ready, the thing is inflating my lungs again, making me take quite short, shallow breaths unless I'm paying careful attention to my breathing. Naturally, paying careful attention to your breathing is not conducive to sleep. My pulse-ox is telling me that my resting state is 99% O2 saturation, but put on the machine and I drop to the mid-90's.

Mask seems OK to me. I don't really feel it after a few minutes, though I do find that I'm paying careful attention to my body position to ensure that the seal is good. Again, careful attention and sleeping are kinda opposites. It's a full nose mask with several cradling straps. I don't mouth breathe so I don't need a full face mask. I've seen the under-nose style, but haven't tried it.
 
Did you have no symptoms? What were the relevant clinical features (aside from the sleep study) to support this diagnosis? Your snoring bothered your wife - was that all? An apnea index somewhat over 5 without any daytime sleepiness does not impress me. Even the saturation lowpoint if it was there but only momentarily, if there is no functional impairment whatsoever during the day; objective sleep study findings alone do not make the diagnosis. They must be combined with clinically significant impairment, at least if you want to be exact. But I understand there is a lot of up coding going on in medicine these days.

If it were me and I had no symptoms I would get this diagnosis overthrown, and I'd tell the wife the guest room is now hers, or move into it myself. Problem solved. No way I'd put up with such a machine unless I had daytime complaints such as sleepiness and cognitive sluggishness.
 
Rushie said:
Did you have no symptoms? What were the relevant clinical features (aside from the sleep study) to support this diagnosis? Your snoring bothered your wife - was that all? An apnea index somewhat over 5 without any daytime sleepiness does not impress me. Even the saturation lowpoint if it was there but only momentarily, if there is no functional impairment whatsoever during the day; objective sleep study findings alone do not make the diagnosis. They must be combined with clinically significant impairment, at least if you want to be exact. But I understand there is a lot of up coding going on in medicine these days.

If it were me and I had no symptoms I would get this diagnosis overthrown, and I'd tell the wife the guest room is now hers, or move into it myself. Problem solved. No way I'd put up with such a machine unless I had daytime complaints such as sleepiness and cognitive sluggishness.
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Just the at-home sleep study with a wristwatch like device that had a finger pulse-ox and a sleep position/snore sensor taped to my chest. My wife doesn't complain about snoring. I don't snore much and it isn't loud. Instead, she says she witnessed the actual apnea episodes repeatedly and wanted me checked.

With BasicMed, I think I'll do exactly as you say. Might still buy the machine just to have it to play with. The question is: can I get my class III back in full standing without the box?

It's hard to know if the apnea is affecting me. I have a baby under a year, so my sleep isn't terribly great to start with. You'll have to ask me in a year or two.

@Rushie , sounds like you're an MD?
 
Notsleepy said:
The pressure isn't high. Between 4 and 6 and its being remotely adjusted this first week by the tech. It has a cell connection and they're monitoring me this week. I only have one night where I managed to wear it all night and it was one of the most miserable experiences I've had in a while. Every other night I've lost it and ripped it off at around three hours. I'm definitely going BasicMed for now...I don't know if I can be 6 hour compliant in the short term. I haven't bought my long-term machine yet...this one is a loaner for trial. (Retail price: $2200. Holy hell. Glad I have an 80% DME coverage.) Dunno yet if I'll buy this exact model.

I believe it already ramps. It does have both a diffuser at the end and it stops pressure on the exhale. But it's not long enough. Before I'm ready, the thing is inflating my lungs again, making me take quite short, shallow breaths unless I'm paying careful attention to my breathing. Naturally, paying careful attention to your breathing is not conducive to sleep. My pulse-ox is telling me that my resting state is 99% O2 saturation, but put on the machine and I drop to the mid-90's.

Mask seems OK to me. I don't really feel it after a few minutes, though I do find that I'm paying careful attention to my body position to ensure that the seal is good. Again, careful attention and sleeping are kinda opposites. It's a full nose mask with several cradling straps. I don't mouth breathe so I don't need a full face mask. I've seen the under-nose style, but haven't tried it.
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4-6 cm is really, really low. I don't think they go any lower than 4.

$2200 is outrageously high, but that's what you get from a DME. You can get one online for a fraction of that. DMEs charge a lot more because - they can. The do provide a service, though, so take advantage of telling them what is or isn't working and get them to make adjustments for you.

It probably is not configured to ramp, you are already so low that there won't be any way for it to start any lower.

The mask will have a diffuser built into it (exhaust port), your CO2 needs a place to escape. The CPAP will pump enough air to account for the loss at that diffuser. The exhale control that's part of the machine settings will program it to lower the pressure when it senses you exhale. Some machines have 2 settings for that exhale pressure relief: one sets the exhale pressure, the other sets the sensitivity of when it returns or how sharp the pressure change is. In my experience, it's more comfortable to turn that feature off and avoid all the physical distractions of the pressure changes during breathing.

Masks - everyone's physical structure is different, some masks simply fit better than others. If you find the mask isn't sealing properly, go back to the DME for adjustment or try it yourself. If that still doesn't work, get the DME to give you another mask of a different design. Don't be shy about it, that's why they are charging so much. After you find something that works, buy replacements online as needed. The "under nose style" masks are called nasal pillows. Almost like a cannula, except they will have soft inflatable seals that will fit your nostrils. Some people like them, some don't.
 
Notsleepy said:
Just the at-home sleep study with a wristwatch like device that had a finger pulse-ox and a sleep position/snore sensor taped to my chest. My wife doesn't complain about snoring. I don't snore much and it isn't loud. Instead, she says she witnessed the actual apnea episodes repeatedly and wanted me checked.
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Yeah that's totally different.

It's hard to know if the apnea is affecting me. I have a baby under a year, so my sleep isn't terribly great to start with. You'll have to ask me in a year or two.
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Great point! Congrats on the baby!!

@Rushie , sounds like you're an MD?
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No. But I went through a sleep study because I have episodes of waking up not breathing, and have to sit up in bed and force myself to restart. So I learned about it. My test was negative, no apnea episodes at all. I do not have obstructive sleep apnea. There is such a thing as central sleep apnea which I also don't have. The doctor said I just have rare instances where normal sleep paralysis which isn't supposed to include your breathing, sometimes crosses wires and includes breathing. Obviously not all the time or I'd never dream, or I'd die in my sleep. (Maybe that's what's going on with SIDS??)

I have never found any reference to this in my reading and had finally considered that the doctor was just making stuff up. Then last month I was in the pre-op for a colonoscopy, the anesthesiologist stopped by to talk to me and asked if I had any sleep apnea so I told him about this, and he said, "My wife has the exact same thing! And her doctor told her the exact same thing!" He described exactly what his wife does when this happens and included details I hadn't yet told him, so I know he wasn't making it up. His description of what his wife does is identical to me.

So there's at least one other person in the world who has this thing and at least two doctors who speculate that it's a variation of sleep paralysis.

Anyhow that's why I'm interested in the subject.
 
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