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Permalink Reply by Mike Fritz on June 17, 2009 at 12:34pm

Secod night the titration

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Permalink Reply by Mike on June 17, 2009 at 1:57pm

copying sleep study results here, in easier to read fashion:

INITIAL SLEEP TEST

TITRATION SLEEP STUDY

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Permalink Reply by B Robles MD on June 17, 2009 at 3:41pm

Dear Mike,
I agree with Mike above that your AHI of 79 is very high and so is your pressure setting. I guess a question for your doctor would be, is he happy because your AHI has come down from where it was? Even so, you really need to get down to a as low a range as you can achieve, certainly less than 10. Its great for you to feel better, but I hope the data has improved. As for "all the green mean", I am not sure in what context he or she is using it in. Ask the doctor why he thinks you are doing great and how you have improved. Your doctor should help you understand the data so that you can be informed. B Robles MD

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Permalink Reply by Daniel on June 17, 2009 at 3:50pm

I find it surprising that the diagnostic test (the first night without CPAP) shows that there were actually almost no apnea events (7) and a huge number of hypopneas (433), The second night, with CPAP, there was a tremendous increase in apnea events for the first half of the night, while the pressure was low. Yet when you used the CPAP at home, at 17 for the whole night, there are almost no hypopneas, and a tremendous number of apneas for the whole night.

Either the CPAP is causing apnea events, or the criteria to distinguish apnea from hypopnea is very different among the three data sets (diagnostic, titration, and CPAP data). Add to that the need to supplement with oxygen and you have a very complex situation.

Do not try to solve this with advice from the internet. Seek out a good sleep physician. You may even have to do your sleep studies over again.

All of the above is my opinion only, not medical advice.

Daniel

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Permalink Reply by Mike on June 17, 2009 at 5:29pm

Not to be too alarmist here, but your heart is taking a beating (no pun intended) right now because of the lack of adequate treatment for sleep apnea, and you need to urgently resolve this.

j n k said:

I agree completely with Daniel's take that a good sleep doc is important and this doesn't look like the kind of thing that is easily understood over the internet, let alone solved. Your medical history and overall health come into play in ways that can't be figured out, imo, as far as second-guessing what your doc may or may not have in mind. In the meantime, though, if it was me, I would at least find a way to be sure I was not sleeping on my back, and I would want oximeter proof that my oxygen saturation was being addressed sufficiently. In my opinion, your titration does not prove that, so I would ask about using an overnight recording oximeter for a few nights so the doctor can know how much oxygen is in your blood overnight.

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Permalink Reply by RockRpsgt on June 17, 2009 at 9:07pm

I agree with you jnk. I would rather switch to BiPAP at 15. The fact of the matter is that the AASM does not decide who is eligible for BiPAP and who is not. That matter is between the individual labs and the insurance companies. We all know that the insurance companies make up the rules and the rest of the medical industry usually falls into line. So for now 15cmwp for a child, and 20cmwp for an adult. This is pretty much insurance standard across the board. Those are the rules. i have to abide by them until they change them.

j n k said:

Rock,

What you say is exactly how many titrate.

But I feel strongly about the application of the 2008 words of the AASM that "if continued obstructive respiratory events at 15-cm H2O of CPAP are documented during the titration study, the patient may be switched to BPAP." (Italics mine) That puts it in the realm of a call for the tech, in my opinion, and I think it is a given that 15 cm is uncomfortable for any patient starting out on CPAP, even if they might, eventually find a way to get comfortable with it. So I interpret "may" to mean that it is within the judgment of the tech to make that call as soon as 15-cm is reached, as far as the AASM is concerned, and that a tech may also make that judgment BEFORE 15-cm is reached "if the patient is uncomfortable or intolerant" at a pressure that feels high to the patient.

That is my interpretation, anyway, of the 2008 AASM statement 12:

"(12) If the patient is uncomfortable or intolerant of high pressures on CPAP, the patient may be tried on BPAP. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the patient may be switched to BPAP."

http://www.sleepguide.com/profiles/blogs/titration-guidelines

As far as I am concerned, any patient who hits 15 cm has been judged by me to have failed CPAP. :-) But I understand if others do not see it that way, and I respect that.

jeff


Rock Hinkle said:

jnk i am not in a place to verify, but it is my understanding that you must prove a failure of CPAP to innitiate BiPAP. This would nean that either the presence of true CSA or a CPAP titration pressure of 20cmwp that does not end events in adults. Children would fail cpap AT 15cmwp with continuous events. With that said the fact that he is on o2 tells me that bipap might be helpful, but i don't know what his diagnostic or titration stated.

the only thing shown in this data that's good is compliance, which is probably the only thing the pcp cares about. i would immediately start looking for a new sleep doc



j n k said:

If you required more than 15 cm of pressure during your titration study, you should have been titrated for bilevel, according to my understanding of present accepted protocol.

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Permalink Reply by Robert Burcham on June 18, 2009 at 8:52am

Looking at 1 days data does not tell us anything really. Patients new to CPAP especially if they have other issues and since you are on 2 liters of O2 as well you certainly qualify, you can develop what are called central apneas. A central apnea is where you just don't get the signal to breath. This may go away after a few weeks. What the machine does not show you is oxygen desaturations, respiratory effort or arousals so it is unclear if they are obstructive or central.
Give your machine 2-3 weeks and look at the data and see if those numbers decline. If not you should request another study with CPAP all night. However the best advice I can give you is to consult a sleep physician.
And for the BiPAP comment, BiPAP is for patients that do not tolerate CPAP and insurances don't just pay for those without a lot of data to support those claims. BiPAP is also not the easiest thing to adapt to and a lot of patients hate it.
So short version, go see a sleep specialist.
Good luck

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