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[CPAP] Go from CPAP to APAP?
#1
I've been using CPAP for more than 5 years. Started out with pressure of 10, and currently, since another sleep study last month, at 13.

I've been able to get the first part of a new sleep lab report in past few months, but not a copy of the titration part yet.

This November's observation study showed "There were 7 central and 41 obstructive apneas seen, with 143 hypopneas also noted for a Total Respiratory Disturbance Index of 43 events per hour increasing
during REM sleep to 65 events per hour. These events were associated with arousals and desaturations commonly into the 90's and under with a low 02 sat of 85%."

Q1: Which, if any, of those numbers is my AHI?

My current machine, the Remstar M series, has only minimal data, mostly just compliance. So I'm looking forward to getting a new machine, probably the new "For Her" A10. I'm also trying out some different masks. Used the Swift for her nasal pillows until last November when a sleep tech suggested the Airfit nasal pillows. The Swift worked OK, but sometimes had nosebleeds, and discomfort around my cheekbones on both those masks. Airfit was annoying for a side sleeper who moves around a lot because the hose doesn't swivel. And the nasal pillows are not that much softer.
Now trying the Wisp, and after the first night, appropriated the bottoms of some pajama legs for microfleece to wrap around the so-called "fabric" part of the headgear which was just as stiff as the other masks I used. It seems I have a smaller head than the standard used by the makers of headgear. Unsure Last night was very uncomfortable so I hope tonight will be better.
And, my mouth does open, so I have been using a chin strap as well. I only mildly claustrophobic, but enough to resist a FF mask.

My condition is very likely congenital as my brother has severe apnea and we now believe both our mother and maternal grandfather died from conditions caused or accelerated by undiagnosed sleep apnea.

All that is context to ask this:
Since Medicare only pays for a new machine every 5 years, I need to anticipate that the new one will meet my needs when I'm a good bit further into my 8th decade.

Q2: What machine recommendations? I have no idea whether I should stay on fixed pressure, or move to APAP.

Q3: Also, should I get an oximeter?

I've learned a lot reading this forum the p
ast few days. Wish I had looked at this sooner!

I've moved twice since getting my first machine, so not in touch with original doctor, and only last week met new doctor for the first time. So before I bombard him with questions, grateful for any first-hand observations or advice from the experts here.




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#2
Helllo Airsign! Can you get a loaner machine from your DME to try out? I like my Airsense A10 for Her. I like the Auto because you get only as much pressure as you need at that moment. But you will probably want to make a decision based on finances, insurance coveraqe, health coverage, etc. they are not cheap.

I personally don't think you need an O2 meter, yet. It sounds like your past settings were not keeping up with the pressure you needed to stop the apneas, and so then your O2 dropped. But your Dr could tell you more, based on your overall health and any other conditions. That titration study is important because it will show the effects of the correct pressure (i.e. stop apneas, and keep O2 up).

I'm still getting used to the varying definitions, but your RDI is similar to the AHI (43). During your deepest sleep (REM) you were waking more than a once every minute! Wow, you must feel exhausted!

Keep us posted with what you are doing! Others here will have more feedback for you!
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#3
Hi AirSign and welcome aboard
We always get more events during REM sleep or/and in supine position

Respiratory Disturbance Index (RDI) is always higher than AHI as include respiratory event-related arousal

RDI per hour:
Total numbers of of apnea (obstructive + centrals) + hypopnea + Respiratory Effort-Related arousal (RERA) and divided by hours of sleep

As for Q2 machine recommendation ... your choice of AirSense 10 AutoSet for Her is good one as this machine reports RERAs
(others models do not)

and for Q3 ... Oximeter is not required in my book at this stage, machine set properly provide ample oxygenation
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#4
Thanks, trailrider. Yes, I've been exhausted -- napping more than once a day. Unfortunately, my current CPAP doesn't tell me much except how many times the airflow is turned off during the night, which I do for trips to the loo.

The REM part has also been bothering me because I don't want to wake up for all the dreams. Once a night, OK Big Grin

I think my insurance will cover a new machine, but maybe I should do a trial first. I'll check on that with the DME.
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#5
Its a little complicated. AHI is a summary of hypop, central, and obstructive, per hour, so 43 is your AHI. RDI is AHI with RERA included, but those events are not mentioned in your quote.

Many major xPAP manufacturers do not even pay attention to RERA as a separate issue. Possibly they assume that if you have an apnea that is severe enough to arouse you, that this has already been counted, and flagging an arousal is splitting hairs because any apnea long enough to be flagged as an apnea is already associated with a partial arousal. I don't know. Some think its important; some ignore it altogether. I guess if it were really important certain manufacturers would not ignore it.

But what sticks out is that you are not a classic OSA sufferer; your makeup of event types is more of a complex apnea situation, and also in the severe category (AHI over 30). So you may need something more sophisticated than CPAP or APAP. You may also need 02, and an oximeter, but let the docs figure all of that out for you. They have the training, you write the checks, which is the quid pro quo that all of this is based on. A full, titrated PSG will graph your 02 desats and tell the doc exactly what is going on, and whether the xPAP would be enough.

I think you are right to be concerned; not because of the severe SA, but because everyone should be this concerned. It is a matter of life and death, or at a minimum, a matter of life and a longer life, for nearly everyone who is a sufferer.

Personally, I feel they should just stop making CPAP machines and make APAP for those not needing ASV/Bi-level, etc., because APAP (when tuned appropriately) is a better therapy for almost every OSA sufferer, and the machine can be run in CPAP mode if that is what is indicated.

But what you realiy need is an informed sleep doc that can figure out what you really need. Don't rely on the internet to make this decision; that would be like learning to remove your own gallbladder by spending a couple of hours on WebMD. Use the internet to find the right doc, and to understand the different machines available, but let the doc figure out what you really need.

I recommend finding a neurologist with a fellowship in sleep medicine. Maybe a pulmonologist. You want someone who sees a lot of sleep patients, not an ENT who sees a lot of sore throats, so a connection with a sleep-oriented company can be of advantage.

So if it were me I would research the possibilities of xPAP only to become informed enough to discuss with a real professional, and let them decide. ZocDoc is a good place to start researching sleep docs, which is what you really need to be concentrating on.

Not that your intentions are not good, they are. Research the machines and the therapy not to make a decision about the machines and the therapy, but to be able to hold an intelligent conversation with the sleep doc who can make an informed decision for you based on his years of knowledge and experience, and the sleep study. But coming here is also a good idea, as it can help you understand the therapy better and help guide the docs to help you get the best machine and the best therapy.

Once you get a good sleep doc and are satisfied, use SleepyHead or other software and monitor and keep track of everything; take control of your own therapy. But the first step is to let the pros do their thing. It sort of sounds like you may need to help them; like you are not getting the full story yet. You don't need to sharpen a stick before you meet with them, but it may take some persistent pressure on your part, which is sadly very common.

I think that is the way to make the best decisions about the xPAP machine, as well as the best decisions for your continuing health.
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#6
Hi AirSign,
I would ask your Doctor for an Auto CPAP, with a heated humidifier and heated hose. Ask him or her to write on script "patient choice", this way you can get whatever machine you decide on.
You can use an Auto CPAP machine either in Auto mode or straight CPAP mode if you want.
Medicare will pay the same no matter which machine you get.
Good luck to you, and keep in touch!
OpalRose
Sleep-well
OpalRose
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#7
Thanks, Zonk, very helpful. Thanks, TyroneShoes, very thorough advice.

My new MD is a pulmonologist. The suggestion about a neurologist makes some sense, though, and I'll discuss it with my PC when next I see her. I may also mention it to my cardiologist next week. I have a prosthetic aortic valve, and it's in good shape but the sleep issue is important for me for that reason also.

There were no "RERA" reported in my sleep lab.

It's not that I won't consult the medical pros --- it's just that I find it hard to believe that I've gone this long, using CPAP therapy, without really knowing what I was doing and without any monitoring, except for when I was in rehab after the open heart surgery 3 years ago. Then my machine was checked and reset, perhaps because I had to sleep on my back the whole time which is not usual for me.

Anyhow, I'm paying attention now. And looking forward to being able to learn just what does go on when I'm supposed to be sleeping.

So, when I get my machine, I'll be checking into the software.


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#8
(03-15-2015, 07:12 PM)AirSign Wrote: I've been able to get the first part of a new sleep lab report in past few months, but not a copy of the titration part yet.

Welcome to the forum, AirSign.

For your own records, you have a right to receive the *full* report, including all data, for both of your recent sleep studies. So please put on your assertive hat and insist on receiving copies of the full reports.

Don't let anyone tell you you wouldn't understand the details. There is important information in the details and, with help from the forum, you would be able to understand most or all of it.

(03-15-2015, 07:12 PM)AirSign Wrote: This November's observation study showed "There were 7 central and 41 obstructive apneas seen, with 143 hypopneas also noted for a Total Respiratory Disturbance Index of 43 events per hour increasing during REM sleep to 65 events per hour. These events were associated with arousals and desaturations commonly into the 90's and under with a low 02 sat of 85%."

Q1: Which, if any, of those numbers is my AHI?

I think this would be more clear if you had the full report.

AHI (Apnea Hypopnea Index) is the average number per hour (of sleep) of Apneas plus Hypopneas.

RDI (Respiratory Disturbance Index) is the sum of the AHI plus the average number per hour of RERA (Respiratory Effort Related Arousal) events. RERA events are arousals caused by excessive respiratory effort but which were not classified as hypopneas because the arousal was not accompanied by a reduction of at least 40% or 50% in how much air was being breathed.

The portion of the report summary which you quoted makes no mention of RERA events. Some patients have no RERAs, which I suspect may have been the case in your observational study (also called the "diagnostic study").

If your average number of RERA events were zero, then the AHI would have been equal to the RDI (43).


(03-15-2015, 07:12 PM)AirSign Wrote: Q2: What machine recommendations? I have no idea whether I should stay on fixed pressure, or move to APAP.

If during your titration you continued to have only an insignificant number of central apneas (CA events) then I would strongly recommend a good APAP machine such as the Philips Respironics System One REMstar Auto with A-Flex and Heated Tube or the ResMed AirSense 10 AutoSet For Her with ClimateLine heated tube, because APAP machines all give you a choice to use the machine in fixed-pressure "CPAP" therapy mode or in APAP therapy mode. And because I recommend getting the optional heated tube option, especially if getting a Phillips Respironics machine.

You had only 7 CA events out of a total of 191 events. (7 + 41 + 143 = 191)

If 191 events represented an RDI of 43 events per hour, then you would have slept about 4.4 hrs. 7 CA events in 4.4 hrs would have represented about 1.6 CA events per hour, which is regarded in the medical community as an insignificant amount.

On the other hand, if during your titration study your CAI (Central Apnea Index, the average number of CA events per hour) was higher than 5 and made up the majority of apnea events, then I think Medicare should be asked to pre-authorize titration with an ASV (Adaptive Servo Ventilator) machine which would be able to treat both the obstructive and the central apneas.

Take care,
--- Vaughn


Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
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#9
Hi, OpalRose.

I think that is what the MD said -- I can get any machine I want. All the info has already gone to the DME except the doctor's notes, because he wasn't in the office to sign them, so they will get faxed to DME this week.
I'll change my profile info when I get the new therapy gear in place.

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#10
Wow, thanks Vaughn!

I do have the full diagnostic report, but didn't want to quote a whole lot of it this time, especially the stuff I don't understand.
You are correct that neither CA nor RERA were significant.
Yes, total sleep period was 440 minutes. Of that, side sleep was 216 min. and supine was 48.5. I suppose the difference of that total from 440 was time awake.

Hope the promised titration results arrive in the mail soon -- lab director said he was mailing them a week ago.
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