Replies to This Discussion

Permalink Reply by Mike on March 28, 2010 at 10:56pm

I'm afraid REM Sleep is achieved later on in the sleep cycle, and not in the first part of the night. But why limit the analysis to REM sleep? Certainly, achieving earlier stage sleep, and Deep Sleep, is quite an accomplishment and can do wonders for how you feel and think. Would studies showing that be helpful to you?

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Permalink Reply by sleepycarol on March 29, 2010 at 7:53am

Just try to keep increasing the length you wear the mask.

You say you are almost there, that is a good thing!!

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Permalink Reply by RockRpsgt on March 29, 2010 at 9:40am

Mike is right. REm sleep is greater in the later sleep stages. You should continue to try and wear your unit as much as possible. All you can do is try. I did some research on this subject a few months back. I came up with some pretty interesting facts. there is a discussion here on SG, but i could not find it. This link is to the discussion I had on binary. I hope it helps Ross. Remember baby steps. This is not a race.

http://www.binarysleep.com/phpbb2/viewtopic.php?t=7518&highligh...

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Permalink Reply by Renee on March 29, 2010 at 12:55pm

Hello Rock ~

The thread that you suggested on Binary indicates that some labs request that their clients NOT use CPAP for 2-3 nights prior to their titration because using CPAP right up to the night of one's titration allows for "muscle memory" to cause one to have a decreased # of events at the titration and, therefore, the titration does not reflect an accurate representation or interpretation of one's actual apnea. What do you think about this idea?

Best,
Renee

Rock Hinkle said:

Mike is right. REm sleep is greater in the later sleep stages. You should continue to try and wear your unit as much as possible. All you can do is try. I did some research on this subject a few months back. I came up with some pretty interesting facts. there is a discussion here on SG, but i could not find it. This link is to the discussion I had on binary. I hope it helps Ross. Remember baby steps. This is not a race.

http://www.binarysleep.com/phpbb2/viewtopic.php?t=7518&highligh...

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Permalink Reply by RockRpsgt on March 29, 2010 at 4:59pm

Renee,

The problem is not so much with initial titrations as it is with re-titrations. Our lab right now has a 4-6 week delay in between the diagnostic and titration study. to alleviate the wait our doctors try to get our pts on PAP as soon as possible. At the time of titration most of our pts have been on PAP for a few weeks. This actually helps us. We are less likely to over-titrate someone as their systems are already used to the therapy.

I am not sure how accurate the numbers from the above studies our. They definatley make you think though. The studies say that continuous PAP use could drop your AHI by up to 15 events per hour. This effect could last anywhere from 1-7 days after discontinuing PAP. Over that time most will progress back to their original severity. When someone comes in for a re-titration we are required to reprove the need for PAP therapy. To do this we have to run a baseline study (diagnostic) once again. This would have been the part of the study done without your mask.

Let's look at a patient whose original AHI was 25. Most lab protocols call for an AHI of at least 20 to initiate a titration or activate split protocol. These numbers are lowered in cases with cardiac events and severe destats (<70%). If a person conistantly uses PAP prior to the re-evaluation it is possible that their AHI would be around 10 during the study. This could cause a tech not to split a patient. If that patient is trying to replace a broken PAP unit this could add a long aggrivating wait to their therapy. A seasoned tech knows that AASM and CMS guidelines will allow you to split a pt with an AHI>5.

To answer your question I am for anything that does not cause an interrruption in therapy. At my lab I am given the freedom to use clinical judgement in these situations. I will also add that some of the individual insurance companies are more strict on the requirements for performing splits and titrations. Anthem has some of the toughest interpretations that I have seen so far. I hope this helps. I have not been up for very long. If you need more explanation please ask.

Rock

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Permalink Reply by Renee on March 29, 2010 at 6:29pm

Hey Rock ~

That’s a great answer! The reason I am wondering is because I have some particular issues.

Here’s the picture . . . I have had an original sleep study and 3 titrations and I have been using CPAP since 12-15. Also, my pressure was raised from 9 to 12 in January – without affecting any change to my AI or AHI. The good news is – I monitor my AI and AHI daily through my ResMed S8 Elite II readings – and with CPAP my OSA has improved – AI down to 1 / hr; HI down to 3 / hr – so, AHI down to 4 / hr.

However, since I remained fatigued, my sleep doctor had me come in for a 3rd titration on 2-23 because I had so little S-3 – 6.3% and REM – 0.6%, along with florid alpha intrusion at my 2nd titration . And, then, on the 3rd titration, my S-3 went down further to 2.8% and my REM went down to 0.0% and I continued to have extensive alpha intrusion. (I listed below a breakdown of my sleep stages – fyi.)

I am now taking 200 mg of Neurontin at bedtime and my sleep doctor in considering a 4th titration in a reasonably short time after I have been on the Neurontin for a while – to see if the titration would be able to detect what affect the Neurontin might be having re: SWS, REM and alpha intrusion.

I’m wondering what your thoughts are, for a whole assortment of reasons, for me to maybe be off CPAP for a couple of days prior to my next titration ?

A complex question, eh? I am certainly not asking you to not take any leap of responsibility here. I am thinking of it more so as an exercise of curiosity – of course, when you are rested and have nothing else to do . . .

Thanks MUCH,
Renee
___________________________________________

Sleep Stages – S-1 . . . .S-2 . . . .S-3 . . . REM
___________________________________________

2-23-10
3rd Titration
WITH CPAP . . . .41.2% - 56.0% - 2.8% - 0.0%

12-15-09
Started CPAP
Treatment at Home

11-17-09
2nd Titration
WITH CPAP . . . .42.9% - 50.2% - 6.3% - 0.6%

9-15-09
1st Titration
WITH CPAP . . . .68.2% - 18.6% - 6.5% - 6.7%

9-8-09
1st Sleep Study
W / OUT CPAP .35.6% - 35.9% - 20.2% - 8.4%
___________________________________________

Normal Sleep
Architecture . . . .5-10% - 45-55% - 20-25% - 20-25%
___________________________________________

Rock Hinkle said:

Renee,

The problem is not so much with initial titrations as it is with re-titrations. Our lab right now has a 4-6 week delay in between the diagnostic and titration study. to alleviate the wait our doctors try to get our pts on PAP as soon as possible. At the time of titration most of our pts have been on PAP for a few weeks. This actually helps us. We are less likely to over-titrate someone as their systems are already used to the therapy.

I am not sure how accurate the numbers from the above studies our. They definatley make you think though. The studies say that continuous PAP use could drop your AHI by up to 15 events per hour. This effect could last anywhere from 1-7 days after discontinuing PAP. Over that time most will progress back to their original severity. When someone comes in for a re-titration we are required to reprove the need for PAP therapy. To do this we have to run a baseline study (diagnostic) once again. This would have been the part of the study done without your mask.

Let's look at a patient whose original AHI was 25. Most lab protocols call for an AHI of at least 20 to initiate a titration or activate split protocol. These numbers are lowered in cases with cardiac events and severe destats (<70%). If a person conistantly uses PAP prior to the re-evaluation it is possible that their AHI would be around 10 during the study. This could cause a tech not to split a patient. If that patient is trying to replace a broken PAP unit this could add a long aggrivating wait to their therapy. A seasoned tech knows that AASM and CMS guidelines will allow you to split a pt with an AHI>5.

To answer your question I am for anything that does not cause an interrruption in therapy. At my lab I am given the freedom to use clinical judgement in these situations. I will also add that some of the individual insurance companies are more strict on the requirements for performing splits and titrations. Anthem has some of the toughest interpretations that I have seen so far. I hope this helps. I have not been up for very long. If you need more explanation please ask.

Rock

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Permalink Reply by RockRpsgt on March 29, 2010 at 9:04pm

That is an enigma wrapped in a riddle Renee. I would like to research your question and situation a little more before answering. Give me a day or 2. Coming off of PAP prior to titration is something that needs to be discussed with your physician. I do not see how it would benefit your situation. They do not need to reprove that you need CPAP. Your next study will be one of exploration rather than diagnosis. Your problem seems to be one of efficiency.

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Permalink Reply by RockRpsgt on March 29, 2010 at 9:09pm

Renee I am very proud of you. Your fighting an uphill battle to better health. Your determination to figure it out is inspiring.

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Permalink Reply by Renee on March 29, 2010 at 9:40pm

Hey Rock,

Thank you so much for all your generous and caring support . . .

Just one question - when do you ever sleep ?!?

My best to you,
Renee
_____________________________________________________

Rock Hinkle said:

Renee I am very proud of you. Your fighting an uphill battle to better health. Your determination to figure it out is inspiring.

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Permalink Reply by RockRpsgt on March 29, 2010 at 10:57pm

I have to make an appointment to sleep. I do not seem to have any this week. I can't slow down cause the clowns will get me.

Renee said:

Hey Rock,

Thank you so much for all your generous and caring support . . .

Just one question - when do you ever sleep ?!?

My best to you,
Renee
_____________________________________________________

Rock Hinkle said:

Renee I am very proud of you. Your fighting an uphill battle to better health. Your determination to figure it out is inspiring.

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Permalink Reply by Renee on March 30, 2010 at 11:27am

Oh dear, Rock ~

Guess it's tooth picks for you to keep your eyes open in the control room this week . . .

On my end, the plot thickens this morning. I generaly wait things out a bit and, as I have been monitoring my AHI through my ResMed S8 Elite II readings, I have been aware of a trend that has been developing since I increased the Neurontin recently. A week ago my HI level doubled and has remained consistently high and my AI has increased 3 times over the last week and is now 3 to 4 times higher than what it it has been over the last few months - eg: AI went from .8 or 1 / hr on avg up to to 3.4 and HI went from 2.5 to 3 / hr on avg up to 5.9 - so AHI up from, say 3.5 to 4 / hr on avg up to 9.3. Oh, and, fyi - my leak rate is .06 L/s.

So, I sent an email to my sleep doctor advising him of the increase in my CPAP levels and asking him if I should continue taking the increased dose of Neurontin.

I happened to speak with him VERY briefly on the phone yesterday. He is VERY busy. He is Omar Burschtin, M.D., F.C.C.P., F.A.A.S.M., Dipl’ A.B.S.M., Director, Sleep Consultation Services, Assistant Professor of Medicine, NYU School of Medicine - with all those initials and all those duties - yes, he is very busy. So, he is not going to, necessarily, want to receive an email from me this morning. BUT, I thought it important enough to contact him - I did think, after all, him being the prescribing doctor and all, that he would want to know about this. HOWEVER, he STRONGLY believes that patients should NOT consult their CPAP machines for Efficacy Data because it is too imprecise and, although he hasn't come out and said it, because patients can't understand their CPAP data worth a darn. That's for the professionals ! So my bringing up anything related to Efficacy Data is a VERY SORE SUBJECT and I always try to find any other basis for discussion with him. But, in this case, it was the Efficacy Data that illuminated the trend and so I had to tell him about the Efficacy Data in relation to my query regarding my continuing taking the increased level of Neurontin.

I expect he will likely call me today and it will be interesting to see how we'll talk about my CPAP being higher, yet all the while, not validating it in relation to my Efficacy Data - since that, and my understanding of it, is unreliable. But, he is a good guy - and so we shall see.

And, for now, wishing you a good - and awake day,
Renee



Rock Hinkle said:

I have to make an appointment to sleep. I do not seem to have any this week. I can't slow down cause the clowns will get me.

Renee said:

Hey Rock,

Thank you so much for all your generous and caring support . . .

Just one question - when do you ever sleep ?!?

My best to you,
Renee
_____________________________________________________

Rock Hinkle said:

Renee I am very proud of you. Your fighting an uphill battle to better health. Your determination to figure it out is inspiring.

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Permalink Reply by Ross Plotkin on March 31, 2010 at 7:18pm

Thanks much for everyone who applied to this.

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