How do you feel about sleep providers electing not to score RERAs?

How do you feel about sleep providers electing not to score RERAs because they are not recognized by Medicare and most insurance companies? We are moving to a new system next month. The collaborative group of sleep providers have voted RERAs out of our reports. I am the sleep lab supervisor and not likely to get a vote, but if I could provide them with more information to make their decision that may help. 

Thanks for giving me the chance to pound the dead horse (to some) I’ve been pounding for several months now. To start, it would be most interesting to learn the rationale for a board-certified sleep specialist opting out of the accepted nosology of the American Academy of Sleep Medicine (AASM) that defines the respiratory effort-related arousal as the discrete scoring event used to diagnose the sleep breathing disorder known as upper airway resistance syndrome (UARS). And, even though some in sleep medicine no longer use the UARS term, the AASM declared in the 2005 nosology that any breathing event may be counted in the RDI.[1] Of course, OSA patients can and often do show RERAs on their studies as well. Thus, an event index of 5 or 15 per hour comprised of apneas, hypopneas, or RERAs is now given the broad name, obstructive sleep apnea (OSA). So, even if the only events were RERAs, it would still be called OSA, and per that nosology the patient meets criteria for a scientifically validated sleep breathing disorder, regardless of the policies of any insurance carrier or government agency.

From a clinical standpoint, the more pressing issue for your sleep facility is the AASM mandate to treat and eliminate RERAs on a titration sleep study,[2] albeit the policy leaves open the option of scoring these more subtle breathing events for reasons that seem contradictory. There is an extensive discussion on the “RERA paradox” in the past two issues of the Journal of Clinical Sleep Medicine. The short round of commentaries delve into the differing perspectives about RERAs, but all reach the same conclusion that RERAs must be treated, so the real paradox surrounds the rationale for the AASM offering an “optional” scoring rule.[3-6]

If a center chooses to ignore RERA scoring, it could still meet AASM standards as long as their sleep technologists were trained to aggressively titrate out the RERAs when determining the best pressures for patients sleeping in the lab. The question arises then whether not scoring RERAs sends the wrong message to sleep technologists who might assume “if you don’t score it, why titrate it?” Moreover, if you don’t score it, there is a strong potential to not see it on the tracing. Indeed, in our numerous conversations with sleep technologists we often hear they are instructed to titrate out apneas and hypopneas only, which often segues to the question, “how exactly do you score a RERA, anyway?”

Another problematic area regarding the guideline to titrate RERAs involves portable auto-adjusting devices, many of which do not score aspects of flow limitation for data download review. Thus, technically, the use of an auto-adjusting device following a diagnostic study of any type does not meet the standards of the AASM, because there is no discernible way to assess whether or not RERAs were addressed. Moreover, even when flow limitation appears on the report, it is usually represented in a graphic on the data charts as some percentage or proportion of time as opposed to the scoring of a breathing event (how could it be scored without EEG?).

Notwithstanding, at our sleep center and in my work with Classic Sleepcare, we stress the importance of looking at these flow limitation patterns, which despite their qualitative nature, often correlate with unresolved sleep complaints among patients whose data downloads show low AHI but persistent “flattening” or “flow limitation.” In other words, it often proves beneficial for patients with these signs of continued sleep breathing disturbances to return for lab-based retitration studies to fine tune pressure settings. For teaching purposes, retitrations are often the single best opportunity to learn to identify RERAs and then titrate them to achieve a normal airflow signal. As described in previous publications,[7,8] usually higher pressures are needed on inspiration to treat RERAs, therefore bilevel devices in general and auto-adjusting bilevel devices in particular can be manually titrated to eliminate all breathing events (AASM standard)[2] while using lower expiratory settings to prevent pressure intolerance.

In sum, despite all the controversies and confusions about RERAs, we consistently find that addressing this aspect of OSA or UARS yields better outcomes and noticeably more satisfied patients. Logically, these results should be apparent to all sleep professionals in that a RERA by definition is triggering an arousal from sleep. By treating RERAs, sleep fragmentation is diminished, so it remains both concerning and questionable regarding any rationale that avoids or minimizes the importance of correcting sleep fragmentation in patients seeking treatment for sleep-disordering breathing.


[1] American Academy of Sleep Medicine. International Classification of Sleep Disorders: Diagnostic & Coding Manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005.
[2] Kushida CA, Chediak A, Berry RB, Brown LK, Gozal D, Iber C, et al. Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med 2008 Apr 15;4(2):157-71.
[3] Collop N. The "paradox" issue. J Clin Sleep Med 2014;10(6):705.
[4] Collop N. Breathing related arousals: call them what you want, but please count them. J Clin Sleep Med 2014 Feb 15;10(2):125-6.
[5] Krakow B, Ulibarri VA, McIver ND. A RERA by Any Other Name... J Clin Sleep Med 2014;10(6):703-4.
[6] Krakow B, Krakow J, Ulibarri VA, McIver ND. Frequency and accuracy of "RERA" and "RDI" terms in the Journal of Clinical Sleep Medicine from 2006 through 2012. J Clin Sleep Med 2014 Feb 15;10(2):121-4.
[7] Krakow B. Paving the Way to Optimal Titrations: The PAP-NAP: A Titration by Any Other Name. Sleep Review. 2011. Magazine Article
[8] Krakow B, Ulibarri VA, Romero EA, Thomas RJ, McIver ND. Adaptive servo-ventilation therapy in a case series of patients with co-morbid insomnia and sleep apnea. Journal of Sleep Disorders: Treatment and Care 2013;(in press).

Barry Krakow MD


Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.

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