Replies to This Discussion

Permalink Reply by Christine C on November 24, 2009 at 6:05am

Rock, you hit the nail on the head..while I was using the AutoPAP I was full of anxiety.
The main reason that they even wanted me to try the APAP was because I was waking up with these horrible headaches. That is what prompted the initial sleep study. After about 2 months on PAP I had begun waking up several times a night, waking up with the headaches again, and feeling sluggish during the day..so much so that I had begun napping during the day again. I am still a newbie at all of this, but why if I am having the same symptoms that I was initially tested for would they start my pressures out so low? I think Saz put it nicely on one of the posts on this thread..I felt as though they basically handed me the APAP machine and said here use this for a week. There was no explanation about how it worked or anything. As I said in one of the posts here that was partially my fault because I assumed that it would be just like using my CPAP. One thing that gets me is that there was another persons data still showing on the machine. How could they even get the right results if there is already someone elses data showing on a machine?
I am grateful that I will be able to switch DMEs. I really feel as though the one I was using totally failed me. When I had first called about the apnea symptoms reappearing was on November 2nd (yes I keep track of dates and that sort of thing when I call the DME). They said they would call the doctor and have him write an order for a trial run with the APAP. I called every couple days to find out if they had contacted my doctor and I was told that the person that handled that was out sick. I understand that people get sick, but that can't be the only one that can make that call. I finally called my doctors office and was told that the order was faxed over on the November 3rd. Well, they finally called me and wanted to deliver the machine. That was onNovember 18th. I finally got the machine on the 20th. Most of you know from other posts how frustrated I have been with this DME. I don't know what I would do without you guys. You have been such a great help to me.....
Its been pretty neat seeing the responses from my initial post. The responses have been very educational and they do actually make sense to me...

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Permalink Reply by sleepycarol on November 24, 2009 at 8:10am

Your point Rock about time seeming like an eternity was where I was coming from. One logically thinks that 2 or 3 minutes is a short period of time, granted it is in the grand scheme of things. BUT when in pain or extreme anxiety it can feel forever!! Try going 2 or 3 minutes actually holding your breath and time is going to seem to slow down, especially while laying in bed with no distractions. It is the distractions around us that helps take the focus off the passage of time. Without those distractions time appears to slow down. Now in reality it doesn't as time is time. Yet our minds can perceive things differently at different peiods of time.

I work in special education and several times a year have student referrals where I go through the process of seeing if they qualify for services. This includes doing diagnostic testing. Depending upon the test that is used, many have timed sections. When you are watching the clock, time seems to slow down.

So that is why I questioned starting the pressure so low -- those few minutes can appear to be forever -- in my opinion.

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Permalink Reply by RockRpsgt on November 24, 2009 at 9:52am

Like I said Saz's way is the right way. Had a titration study not been done this protocol would be exceptional for say 7 days at a time. It is my opinion that the protocol should be modified for someone in Christine's situation. I have been taught that my titrations are considered a starting point for the sleep team involved with the pt. I believe that this protocol ignores the initial titration data. However not being able to talk to your doc and here what he is thinking I am just armchair quarterbacking.

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Permalink Reply by Saz RPSGT on November 24, 2009 at 3:35pm

Rock, you said that 7-17cmH20 would probably be correct. Truth is I would bet that you are correct and that this would be a great range.

I think that the protocol is in place mostly because the physicians are busy. For a physician to scrutinize the initial report and see if there wasn't enough time to titrate, or if there was some kind of mistake. This would take some amount of time. Not a lot of time, but 3-5 minutes is quite a bit. Then they would have to communicate the range to the set-up person. I agree with you wholeheartedly that it would make it easier for the patient to tolerate.

Instead, it is up to the clinician (set up person) to explain that "it will most likely not be perfect sleep, and it will be constantly adjusting to changes in your breathing." Other things are explained so it's a clean trial, but it's understood that this is just the last step in the process.

I think that this has been a great thread. Protocols and expectations with a sprinkle of technical mumbo jumbo. I love it! :^) When I open up a sleep center in my garage I'm calling you Rock, to see if you want to be a business partner!

Saz

Rock Hinkle said:

Like I said Saz's way is the right way. Had a titration study not been done this protocol would be exceptional for say 7 days at a time. It is my opinion that the protocol should be modified for someone in Christine's situation. I have been taught that my titrations are considered a starting point for the sleep team involved with the pt. I believe that this protocol ignores the initial titration data. However not being able to talk to your doc and here what he is thinking I am just armchair quarterbacking.

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Permalink Reply by RockRpsgt on November 24, 2009 at 4:00pm

LOL it's a deal Saz.

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Permalink Reply by sleepycarol on November 24, 2009 at 4:32pm

Can I be the receptionist? I have experience working in an office. I have learned that I know as much as many of the local yokels so I think I could answer the phone and schedule appointments.

I will even suggest to all my friends and relatives to have a sleep study done!!

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Permalink Reply by Saz RPSGT on November 24, 2009 at 5:14pm

You're hired Carol! Sounds like you're the marketing gal as well....bringing in that patient flow. :^)

sleepycarol said:

Can I be the receptionist? I have experience working in an office. I have learned that I know as much as many of the local yokels so I think I could answer the phone and schedule appointments.

I will even suggest to all my friends and relatives to have a sleep study done!!

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Permalink Reply by RockRpsgt on November 24, 2009 at 6:01pm

I like it!

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Permalink Reply by sleepycarol on November 24, 2009 at 6:19pm

Wringing my hands in glee!!! I can't wait!! We will make some kind of team!!

Do you remember the Ghostbusters? Hey Saz, if we outgrow your garage can we move to an abandon fire station? I would love to work in one. In fact there is one not to far from my home that the city sold after they built the new consolidated station, but at the present time someone is using it for storage. :(.

If the abandon fire station doesn't work out maybe an old hospital that we can convert? I am full of ideas!!

LOL!!!!

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Permalink Reply by Andy on November 24, 2009 at 6:53pm

Hi All,

Very interesting discussion!

But there's one thing I'm not clear on, even after the back and forth between Rock and Saz.

If Christine is having problems on CPAP with a pressure of 14, then is it even possible that a lower pressure would work for her? Or are you thinking that the original order for a pressure of 14 might have been a "safe" guess, and that maybe lower pressures weren't even considered?

Am I wrong to assume that, once you hit the "optimal" pressure that eliminates all or most of the episodes, that any additional pressure would not help or hurt? In other words, if I've done a titration study, and the result was that 10 works for me, would 12 or 14 or 18 be worse? I'm not talking about "comfort" but verifiable results.

Once a patient is at an optimal pressure, is there a higher pressure at which the results would start to get worse? I can assume that there would be a lower pressure at which the results would deteriorate...

My line of questioning is also to figure out where the best place to start would be for a titration study, given some patient history on CPAP.

For example, I was on CPAP for about three weeks prior to getting the titration study. I brought my printed results for the period that I had used CPAP, which showed a big improvement on CPAP (as opposed to without CPAP) at a pressure of 10, but that the AI was still around .5, and HI was still around 4-6.

The tech at the titration study said, "Good that you brought this. We can start you off at 10, and make smaller increases until we get really close to a good pressure for you. Without this info, I would have had to start much lower, and make bigger changes in order to get within the right range."

Now, this makes sense to me! It seems to me that starting me off at 10 would get me closer to where I needed to be, and allow more time for "fine" adjustments during titration, rather than "coarse" adjustments. As it turns out, the tech found that a pressure of 12 worked well.

So, am I anywhere near making sense?!!

;)

.

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Permalink Reply by RockRpsgt on November 25, 2009 at 3:36am

Your situation is a little different than Christines, but I will try to explain. Sometimes our airways will get used to the air shint caused by the CPAP. This same effect can help to build muscle memory in our airways. This residual effect can be seen in something called the hysteresis phenomenon (thanks Mollette).

http://www.ncbi.nlm.nih.gov/pubmed/8484626?dopt=Abstract

Andy said:

Hi All,

Very interesting discussion!

But there's one thing I'm not clear on, even after the back and forth between Rock and Saz.

If Christine is having problems on CPAP with a pressure of 14, then is it even possible that a lower pressure would work for her? Or are you thinking that the original order for a pressure of 14 might have been a "safe" guess, and that maybe lower pressures weren't even considered?

Am I wrong to assume that, once you hit the "optimal" pressure that eliminates all or most of the episodes, that any additional pressure would not help or hurt? In other words, if I've done a titration study, and the result was that 10 works for me, would 12 or 14 or 18 be worse? I'm not talking about "comfort" but verifiable results.

Once a patient is at an optimal pressure, is there a higher pressure at which the results would start to get worse? I can assume that there would be a lower pressure at which the results would deteriorate...

My line of questioning is also to figure out where the best place to start would be for a titration study, given some patient history on CPAP.

For example, I was on CPAP for about three weeks prior to getting the titration study. I brought my printed results for the period that I had used CPAP, which showed a big improvement on CPAP (as opposed to without CPAP) at a pressure of 10, but that the AI was still around .5, and HI was still around 4-6.

The tech at the titration study said, "Good that you brought this. We can start you off at 10, and make smaller increases until we get really close to a good pressure for you. Without this info, I would have had to start much lower, and make bigger changes in order to get within the right range."

Now, this makes sense to me! It seems to me that starting me off at 10 would get me closer to where I needed to be, and allow more time for "fine" adjustments during titration, rather than "coarse" adjustments. As it turns out, the tech found that a pressure of 12 worked well.

So, am I anywhere near making sense?!!

;)

.

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Permalink Reply by Christine C on November 25, 2009 at 6:08am

WOW!! What an awesome response! Thanks to all who responded..sorry I havent been more active on the thread that I started. With the holidays things have been crazy and then to top it all off my Mother was admitted into the hospital yesterday and is having Gallbladder surgery this morning.
I hope that each and every one of you have a very blessed Thanksgiving....

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