Sleep apnea SI questions

N747JB

N747JB

Final Approach
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John
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CTJ Carrollton GA
I took a sleep study at the request of the FAA in 2024, results were mild sleep apnea, 11.2 events per hour. CPAP machine, lost 30 lbs and now I feel great, but I’m not using my machine as often as the feds would like. When I use it, my events are from zero to .5 per hour. My last submitted sleep report from my pulmonologist was for 30 days, and they are requesting/demanding 12 months. It will not show enough 6 hour per night usage.
My question is twofold, can I take another sleep study to show I no longer has OSA? Or can I go BASIC MED with this still pending?
Thanks
 
Last first: not now. You will eventually be denied.

C'mon the inital SI auth letter states >75% of nights with > 6 hours.
Can you get within the time limits allowed, 90 days on the report showing >>75% of days showing >6 hour's usage? Eg, when is the FAA's demand information due?
They will commonly accept 90 days ONCE ONLY, and "dress you down in writing that 7% is NOT ELECTIVE and it is over the whole year.

If you do a repeat sleep study it has to be an in-hospital type (or at at home type 2 @about $1,000 -all twelve wires in your hair) and it has to show AHI <5.0 in all positions.
 
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bbchien said:
Last first: not now. You will eventually be denied.

C'mon the inital SI auth letter states >75% of nights with > 6 hours.
Can you get within the time limits allowed, 90 days on the report showing >>75% of days showing >6 hour's usage? Eg, when is the FAA's demand information due?
They will commonly accept 90 days ONCE ONLY, and "dress you down in writing that 7% is NOT ELECTIVE and it is over the whole year.

If you do a repeat sleep study it has to be an in-hospital type (or at at home type 2 @about $1,000 -all twelve wires in your hair) and it has to show AHI <5.0 in all positions.
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My 12 month report was around 75%, 5 1/2 hour usage, through the end of July. The doctor printed 30 days and filled out the report for 30 days. I haven’t been diligent about using it since the appointment, it really hasn’t helped much. The doctor says he can’t do a 6 hour report, only 4 hour, that insurance companies require. I will try to go to his office and use my “myAir” app, but it’s not date selectable, only 12 months back from today. I believe the demand is about 55 days from now.
Dr Bruce, I appreciate your help.
 
myAir shows histograms with a dashed line at 4hrs, but it does show the nights >6 hrs.

Yeah, it doesn’t have a way to set a date range, at least that I can find easily.

OSCAR is a utility that can import all the detail info from your CPAP and format reports pretty much any way you need. But it requires the SD card from the CPAP. myAir doesn’t need an SD card, so it might not be installed in your CPAP.
 
Matthew said:
myAir shows histograms with a dashed line at 4hrs, but it does show the nights >6 hrs.

Yeah, it doesn’t have a way to set a date range, at least that I can find easily.

OSCAR is a utility that can import all the detail info from your CPAP and format reports pretty much any way you need. But it requires the SD card from the CPAP. myAir doesn’t need an SD card, so it might not be installed in your CPAP.
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That’s pretty much what I’m seeing with MyAir as well, 1 month or 12 months previous history. Thanks
 
The SI requires 12 months, > 6 hrs. So myAir will work as long as you have actually been using it. OSCAR will give you the detailed breath by breath data for every night, it's helpful for adjusting your therapy. But it does allow you to print reports for different hours/night and date ranges.
 
So start slamming It for the next 54 days and get all nights for the next as > 6 hrs and the math should work out…you need 68 days of the next ninety >>6 hrs. COUNT you last 30 days and be sure that the 90 day report will exceed 68 days at>>6 hrs…and have your AME upload it or fax it to 404-954-4040 2ds B4 the the demand date..
 
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And so this is where the FAA is asking pilots to do something that isn't terribly supported by the evidence. If you want to keep your medical, you're stuck doing what Dr. Chien recommends.

Having said that, there is no good evidence in terms of a mortality benefit or a clear cardiovascular benefit in treating mild sleep apnea. Some folks have symptoms that improve on CPAP treatment, but many do not and get no clear medical benefit.

I"m willing to wager your AHI is improved. Below 5? Unclear. But #30 of weight loss is significant.

Only about 25% of folks with mild sleep apnea are compliant with their treatment. If you are one of those folks with mild sleep apnea and don't find the CPAP treatment that helpful (so don't tend to use it as regularly as you should), then one approach would be to do what Dr. Chien says to keep up with the terms of your SI until your SI expires then go BasicMed and discuss with your pulmonologist whether or not you really need CPAP.

There are no studies that I'm aware of linking mild sleep apnea with impaired performance in patients who don't have any symptoms (vigilance impairment, high sleep score, excess daytime sleepiness, prior sleep related accident, etc). If you have symptoms, then it's a different story, more complex. (Hence the need for your pulmonologist's opinion before you discontinue your treatment.)
 
Mark K said:
And so this is where the FAA is asking pilots to do something that isn't terribly supported by the evidence. If you want to keep your medical, you're stuck doing what Dr. Chien recommends.

Having said that, there is no good evidence in terms of a mortality benefit or a clear cardiovascular benefit in treating mild sleep apnea. Some folks have symptoms that improve on CPAP treatment, but many do not and get no clear medical benefit.

I"m willing to wager your AHI is improved. Below 5? Unclear. But #30 of weight loss is significant.

Only about 25% of folks with mild sleep apnea are compliant with their treatment. If you are one of those folks with mild sleep apnea and don't find the CPAP treatment that helpful (so don't tend to use it as regularly as you should), then one approach would be to do what Dr. Chien says to keep up with the terms of your SI until your SI expires then go BasicMed and discuss with your pulmonologist whether or not you really need CPAP.

There are no studies that I'm aware of linking mild sleep apnea with impaired performance in patients who don't have any symptoms (vigilance impairment, high sleep score, excess daytime sleepiness, prior sleep related accident, etc). If you have symptoms, then it's a different story, more complex. (Hence the need for your pulmonologist's opinion before you discontinue your treatment.)
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BS!

Mild Obstructive Sleep Apnea Syndrome Should be Treated - PMC

pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov
 
4RNB said:
BS!

Mild Obstructive Sleep Apnea Syndrome Should be Treated - PMC

pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov
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Sorry, but your link doesn't really prove your point. To quote the auther"...The fact that these improved outcomes relate particularly to patient quality of life..." He is acknowledging that the date only supports to an improvement of symptoms. If you don't have any symptoms, an honest critical look at the evidence doesn't mandate CPAP therapy.

As I mentioned, treatment of mild OSA can improve symptoms in patient who have symptoms. Google MERGE, CATNIP, MOSAIC studies, and/or take a look at the USPSTF review on the matter in 2022.

On the other hand, what they did not show is a clear mortality benefit. See the USPSTF review again for their thoughts...USPSTF recommendations via JAMA and two other review articles in JAMA, Diagnosis and Management of Sleep Apnea, by Gottlieb. April 2020, as well as another JAMA review in 2025.

Again, the evidence is not at all clear that treatment of mild sleep apnea with CPAP in otherwise asymptomatic individuals has any clear morbidity and mortality benefits.

For example, the mean BP reduction with treatment of mild OSA with CPAP was 1-3mm Hg. Barely statistically significant. (and, in some studies, again, not statistically significant.)

Do you know what is statistically significant? On average, you can drop your BP 1mm Hg for every 2# you loose. Speaking in average terms, this guy likely dropped his BP 15mm Hg with his #30 weight loss. This is markedly better than what the CPAP has to offer.

I am not this guy's doc and am not giving him specific medical advice. Having said that, he has mild OSA to start, with an AHI of 11. On average, he would likely have a significant reduction in his AHI just with his weight loss. But even if his AHI still met criteria, it would be very, very mild. Say an AHI of 7. The reality is that his 30# weight loss was likely a markedly more beneficial treatment for his mild OSA than a CPAP machine.

There is just no study evidence whatsoever that giving someone with this mild of an AHI would medically benefit from CPAP if they don't have sxs...and in this case especially because he seems to have treated his sleep apnea with weight loss.

Again, I'm not saying never use cpap with mild OSA. I treated lot's of patients with mild OSA with CPAP therapy. But, it's a grey area and it's not mandatory for every patient with mild OSA to use CPAP. The evidence just doesn't support this.

Not fully comprehending the grey areas of medicine is not BS...
 
The number one symptom people with sleep apnea have is...not breathing
The rest is sequelae.
 
4RNB said:
The number one symptom people with sleep apnea have is...not breathing
The rest is sequelae.
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Not sure what point you are trying to make here. Turns out, virtually no one has an AHI of 0. Which means that, pretty much everybody will have an occasional episode of apnea at night.

It's hard to give a concrete number below 5 because most studies just lump everyone below 5 as normal. Normal isn't really 0. So then the question becomes at what point do they become significant and how best to treat them? Because of the way the vast majority of studies break down these episodes, 0-4 per hour is normal, 5-14 is mild, 15=29 moderate and 30 or greater, severe. The data is pretty clear that anyone who is 15 or greater benefits medically from treatment. The data becomes more nuanced between 5-14. You can try weight loss, an oral appliance, side sleeping, giving up alcohol and see if this lowers your AHI. You might benefit medically from CPAP if you're in the mild category, but you might not. That's just what the current study data supports.

PS the author of the particular journal OpEd you referenced acknowledges funding from ResMed, the makers of CPAP and BIPAP machines. Keep that in mind.
 
Mark K said:
Not sure what point you are trying to make here. Turns out, virtually no one has an AHI of 0. Which means that, pretty much everybody will have an occasional episode of apnea at night.

It's hard to give a concrete number below 5 because most studies just lump everyone below 5 as normal. Normal isn't really 0. So then the question becomes at what point do they become significant and how best to treat them? Because of the way the vast majority of studies break down these episodes, 0-4 per hour is normal, 5-14 is mild, 15=29 moderate and 30 or greater, severe. The data is pretty clear that anyone who is 15 or greater benefits medically from treatment. The data becomes more nuanced between 5-14. You can try weight loss, an oral appliance, side sleeping, giving up alcohol and see if this lowers your AHI. You might benefit medically from CPAP if you're in the mild category, but you might not. That's just what the current study data supports.

PS the author of the particular journal OpEd you referenced acknowledges funding from ResMed, the makers of CPAP and BIPAP machines. Keep that in mind.
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I’ll keep in mind that you are a pilot also.
 
4RNB said:
I’ll keep in mind that you are a pilot also.
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Just not getting your points. I'm a pilot, but that is not clearly biasing one way or the other. I don't have sleep apnea and don't have a dog in this fight. I'm not advocating this guy try to get around the terms if his SI. I clearly stated he should follow the rules of his SI. But if his SI expires and he goes Basic Med, then he could legally fly if he had very mild sleep apnea, was not having any symptoms, and his physician agreed/opined that he was not having any symptoms and wasn't really benefitting from CPAP therapy.

There are no studies showing any occupational harm from patients with mild sleep apnea, treated or not, so why unnecessarily restrict them? The DOT does not force truck drivers with mild sleep apnea to use CPAP if they don't have symptoms. Is this just shoddy regulation? No. There just isn't any evidence that this is a problem. I'm all for government regulation.

But overregulation is a thing...
 
The guy does not have to wait until his SI Authorization expires to go BM. My SI Authorization for sleep apnea expires in 2028. My special issuance third class medical certificate is good through Oct 2026. I do not plan on renewing the medical certificate this year, since I also have a BM certificate. I plan on BM going forward and will just let the current medical expire at the end of Oct 2026, and the SI expire naturally due to not submitting the required yearly report. This what I have learned in previous posts on this subject. Keep in mind the two items are different, the SI Authorization and the Medical Certificate.

Edit: I May actual submit the yearly report to keep the underlying SI Authorization valid through 2028 and beyond. I a, fully compliant and get a yearly report free of charge with my annual checkup.
 
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Rcmutz said:
The guy does not have to wait until his SI Authorization expires to go BM. My SI Authorization for sleep apnea expires in 2028. My special issuance third class medical certificate is good through Oct 2026. I do not plan on renewing the medical certificate this year, since I also have a BM certificate. I plan on BM going forward and will just let the current medical expire at the end of Oct 2026, and the SI expire naturally due to not submitting the required yearly report. This what I have learned in previous posts on this subject. Keep in mind the two items are different, the SI Authorization and the Medical Certificate.

Edit: I May actual submit the yearly report to keep the underlying SI Authorization valid through 2028 and beyond. I a, fully compliant and get a yearly report free of charge with my annual checkup.
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This is almost exactly my situation.

I hadn’t thought about submitting the annual reports to keep that SI Authorization valid. I’m still considering finishing the commercial rating. If I decide to use it, getting the class II will require that SI again.
 
Matthew said:
This is almost exactly my situation.

I hadn’t thought about submitting the annual reports to keep that SI Authorization valid. I’m still considering finishing the commercial rating. If I decide to use it, getting the class II will require that SI again.
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I would keep the SI Authorization active by submitting the required data. You don’t want to have to go through the sleep study again unless you are a masochist.
 
I spoke with my AME today and based on the FAA letter, my 3rd class is still valid and I would qualify for Basic Med. I’m going to look into Basic Med as well as up my CPAP usage. Thanks for all the replies!
 
Yeah but when the deadline passes they will deny your 3rd class and then basic will be un-useable, to you.

As to Mark's comments:
Yes an AHI of 7.5 is mild But it one looks at the correlation between AHI (which is inverse to neurocognitive performance), add to that the noncompliance of pilots and the slippery slope to 15 and the general worsening of disease overt time (+ the fact that they certify you for the COMING year), the FAA has chosen to regulate at AHI of 5 (which is, really, 12 minute bursts of REM, just about).

Whether that's appropriate or not we can argue forever.
 
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To be clear, I'm not advocating not treating sleep apnea.

I just think that for the OP, his loss of #30 is in fact a better treatment globally for his overall health.

While thin folks occasionally get OSA, 70-90% of folks with sleep apnea are overweight or obese. (~50% of overweight and obese folks have sleep apnea, whether they've been tested or not.)

From the studies, you can cut your AHI in half on average with a 10% reduction in your starting body weight. For a typical American male in his 200's, 30# represents a loss of over 10%. So, statistically speaking, this guy now has an AHI of 5.5. Yes, he'd have to be retested to actually confirm where he was, but 50% odds he's already put his mild sleep apnea in remission and he has a whole host of other benefits from weight loss.

There is this focus on reducing the AHI as the gold standard. Yes, it's true that as the AHI goes up, the medical risk climbs. And CPAP is brilliant at lowering AHI to less than 5 in folks that tolerate it.

But the studies also are conflicting and don't overwhelmingly show that treating OSA with CPAP (except severe OSA, where the evidence of treatment effect is more clear) significantly reduces hard endpoints as well as cognitive function.

I could make the argument from a rigid interpretation of the study data that pilots with moderate or severe OSA should lose their medical regardless of whether they are treated or not because they do have neurocognitive impairment that aren't fully resolved with treatment. But I'd get flamed off the board...so I won't...

Like I said, for this original poster, after his SI expires he could discuss with his doc and, if appropriate and he can maintain the weight loss, he could just repeat a simple at home level 3 study. It wouldn't satisfy the FAA for a standard medical certification, but from a physiologic standpoint, an AHI of less than 5 on a repeat level 3 study in a patient whose initial study was 11 and had lost #30 would be a very plausible outcome. I would sign his Basic Med form if I thought he could maintain the weight loss. And this is an important rub. Many folks don't maintain the weight loss.

Regain the weight, regain the sleep apnea...

The FAA is stuck making black and white rules in medicine which is inherently very grey. I understand why the FAA is taking the approach they take. CPAP is excellent at lowering the AHI under 5 and this provides a very black and white criteria. The assumption being "you're under 5, everything is ok." It's a straightforward rule to follow. But the rule obscures a lot of subtleties.

Which is why having a thoughtful general internist and Basic Med can be your friend. (Shameless plug for the dying breed of general internists...)
 
bbchien said:
Yeah but when the deadline passes they will deny your 3rd class and then basic will be un-useable, to you.

As to Mark's comments:
Yes an AHI of 7.5 is mild But it one looks at the correlation between AHI (which is inverse to neurocognitive performance), add to that the noncompliance of pilots and the slippery slope to 15 and the general worsening of disease overt time (+ the fact that they certify you for the COMING year), the FAA has chosen to regulate at AHI of 5 (which is, really, 12 minute bursts of REM, just about).

Whether that's appropriate or not we can argue forever
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My 3rd class and SI expire October 31, I have not applied for a new 3rd class yet.
 
N747JB said:
My 3rd class and SI expire October 31, I have not applied for a new 3rd class yet.
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So you still have the option to do a basic med....
or, as you've lost 30 lbs, you can do the new type 2 or type 1 sleep study and if your AHI is 4.9 or less, they'll give you the each of three years running "letter from your PCP as to lack of symptoms and maintenance of leaner body weight, and then dissolve your SI with an "eligibility " letter. They want to know you haven't ballooned back up.

Here's a private vendor: https://axgsleepdiagnostics.com/pro...pliant-7-channel-home-sleep-study-unattended/
 
Jason at agx was great. was very pleased with the whole experience. one note if u use him. it can be a tad bit complicated to make sure everything is hooked up correctly. He is very responsive if u call his number.
 
Update: I had my Basic Med exam yesterday and submitted it today. I also submitted my updated sleep report for 12 months with a note explaining my change of circumstances, I didn’t make any excuses for my inconsistent usage of my CPAP. My question for the group, is do I need to notify FAA aeromedical of my decision to go Basic Med with my CPAP report, or just wait on their reply? My 3rd class with SI expires October 31.
Thanks!
 
N747JB said:
Update: I had my Basic Med exam yesterday and submitted it today. I also submitted my updated sleep report for 12 months with a note explaining my change of circumstances, I didn’t make any excuses for my inconsistent usage of my CPAP. My question for the group, is do I need to notify FAA aeromedical of my decision to go Basic Med with my CPAP report, or just wait on their reply? My 3rd class with SI expires October 31.
Thanks!
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I just did the same thing. Submitted my annual CPAP report, and other items as required by the Authorization. In my cover letter, I told them I wanted to keep the Special Issuance authorization active through its end date of 2028, and that I am now flying under a Basic Med medical certificate which I obtained back in April. Hope it doesn’t confuse them.
 
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