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Finally got the Hubbies Info. Can someone please advise?
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ShelaghDB Offline

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Location: Toronto, Ontario, Canada

Post: #1
Finally got the Hubbies Info. Can someone please advise?
Some of you might know that the hubby came with me for a study as well.
He has a tendance to gain weight and then lose it again and now he's weight more than normal although he has a really broad chest and can carry the weight easily.


The first time they screwed it up as we both slept on our backs and no one told us to sleep on our sides at all.
I heard the doctor at the appointment tell Kevin that he was borderline and just needed to lose weight.
He didn't really want to give Kevin a machine. Kevin had to, for some reason, make him believe he was going to use it.
Ironically he hasn't, partly because of what the doctor said but i know there wasn't anything he said at the appointment that would have made this doctor think he wasn't going to use it.
This is the same doctor I used and absolutely hated.
I will never use him again.

But we just got these papers yesterday.......

SLEEP ARCHITECTURE:

First Sleep onset latency was slightly short.
Sleep efficiency was normal.
The sleep stage breakdown was normal.
REM latency was slightly short. This may represent REM-rebound.
There were 4 REM episodes(s) with normal distribution.

Sleep Fragmentation:
The frequency of arousals was minimally increased but over ½ were due to residual respiratory
events.
The frequency of sleep stage shifts and awakenings was normal.
Alpha Intrusions were infrequent.

Respiratory Analysis: The frequency of residual respiratory events was mildly increased at 14.5/hr
REM but not the supine posture appears to be a risk factor for residual events. The patient actually got worse as the pressure increased.
As such this must be considered an unsuccessful CPAP titration session.
The Oxygen saturation fell below 90% for 6.5% of the night with the nadir being 81%.

Movement Analysis: Restless legs during wakefulness were not seen. The patient displayed no unusual behaviours during sleep. Periodic limb movements during sleep were not seen.

Additional Comments: Cardiac rate and Rhythm were normal.

Impression: An unsuccessful CPAP titration study. ( the previous sleep study was not immediately available for comparison)

Follow UP; By me in my private office at some point in the near future

____________________________________________


Below are the sheets I scanned into my phone with an app/scanner...its not that clear but the sheets are folded so its hard to get a clear scan


[Image: 2z5opid.jpg]

[Image: n1quck.jpg]

[Image: 27z9m53.jpg]

[Image: 25a7kgx.jpg]
(This post was last modified: 06-04-2014 10:39 AM by ShelaghDB.)
06-04-2014 08:19 AM
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ShelaghDB Offline

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Posts: 267
Joined: Sep 2013

Machine: S9 Auto-Set +Resmed H5i
Mask Type: Full face mask
Mask Make & Model: Quattro Air FF Mask
Humidifier: resmed H5i
CPAP Pressure: 13
CPAP Software: ResScan SleepyHead

Other Comments:

Sex: Female
Location: Toronto, Ontario, Canada

Post: #2
RE: Finally got the Hubbies Info. Can someone please advise?
Looking at the sheet, I have now only just of found out that the doctor basically considered the sleep test unsuccessful...One would think he would have been scheduled for another one unless i am reading his numbers incorrectly?

If anyone needs me to clarify any numbers from these sheets I can do so. Unfortunately I don't know why clearer ones weren't sent by fax..


I remember the doctor telling me we both had to have a second sleep study as he felt the first one had not told him anything due to us both having slept on our backs all night.
That was a test where neither of us wore a mask so we both slept all night, the rooms were freezing cold so it knocked us both out......LOL and no one had us sleep on our sides at all so any thing they got was just us each sleeping on our backs.
In any event, I find it somewhat ironic that with two sleep studies, he still seems inconclusive about Kevins.......


I guess this means we need to book a third but with a new doctor....
(This post was last modified: 06-04-2014 10:41 AM by ShelaghDB.)
06-04-2014 10:38 AM
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Peter_C Offline

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Other Comments: Severe obstructive sleep apnea 1999/Just got an ASV machine

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Post: #3
RE: Finally got the Hubbies Info. Can someone please advise?
First, I feel for you both.

I seem to be one of the rare lucky people to stumble into working with a great sleep Doc on the first try (and this was years ago). My wife had a study done bout 3-4yrs back and was 'borderline'. However, she was just not happy with her sleep quality and asked to be put on a CPAP regardless. She was, is 100% compliant and loves her machine. Even though she tested borderline, something about adding the rituals of the machine has drastically improved her sleep.

All I can say is getting a sleep doc that you like, is critical IMO. Best luck to you both!

*I* am not a DOCTOR or any type of Health Care Professional. My thoughts/suggestions/ideas are strictly only my opinions.

"Only two defining forces have ever offered to die for you. Jesus Christ and the American Soldier. One died for your Soul, the other for your Freedom."
06-04-2014 01:36 PM
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ShelaghDB Offline

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Posts: 267
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Machine: S9 Auto-Set +Resmed H5i
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CPAP Pressure: 13
CPAP Software: ResScan SleepyHead

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Sex: Female
Location: Toronto, Ontario, Canada

Post: #4
RE: Finally got the Hubbies Info. Can someone please advise?
Your wife was fortunate.
We on the other hand have had nothing but problems.....

I am not sure if he is borderline...i really don't know what this means and for that matter WHY he would not have been able to have got a proper test result for I KNOW he slept all night LOL

I was up early and we ere the only 2 people there and I know he slept perfectly through the night and the woman that was testing us and I were talking, waiting for him to get up and she told me he slept all night so why they could not get proper tests from that IF this is what this means, I can't imagine.

But looking as if no one else seems to know either as no ones answered it.......
(This post was last modified: 06-04-2014 02:20 PM by ShelaghDB.)
06-04-2014 02:20 PM
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bwexler Offline

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Machine: PRS 1 BiPAP autoSV Advanced, with Heated Tube humidifier
Mask Type: Nasal mask
Mask Make & Model: Sleepweaver Élan
Humidifier: Resperonics Heated Tube humidifier
CPAP Pressure: Max pressure 25.0 cm H20, Max
CPAP Software: SleepyHead EncorePro

Other Comments: CMS 50i with Software for SpO2

Sex: Male
Location: San Marcos, CA, USA

Post: #5
RE: Finally got the Hubbies Info. Can someone please advise?
If he has an S9 Autoset, you can use Sleepyhead and ResScan to do your own Titration. If you get a CMS50x oximeter you will ha your own half sleep lab. Record your your info and share it here for help deciphering it. It seems many sleep docs either don't know or don't care enough to provide the level of help available here.
06-04-2014 02:35 PM
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ShelaghDB Offline

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Posts: 267
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Machine: S9 Auto-Set +Resmed H5i
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Mask Make & Model: Quattro Air FF Mask
Humidifier: resmed H5i
CPAP Pressure: 13
CPAP Software: ResScan SleepyHead

Other Comments:

Sex: Female
Location: Toronto, Ontario, Canada

Post: #6
RE: Finally got the Hubbies Info. Can someone please advise?
Quote:CMS50x oximeter

So to do a Titration when you don't know where to begin for someone, is done, how?

And once you determine the area of pressure that is right for him......you then bring an oximeter into it?
Ive not been told that myself by anyone else yet so I am at present not even sure what that means.......how much it costs OR, what makes that, make this S9 AutoSet a complete sleep study, whereas without this oximeter, it doesn't?

Thanks


So I will assume no one is able to make out IF he has sleep apnea or not? LOL

In any event he does not have an AutoSet.
I am at present trying to figure mine out and i am not doing at all well with it.
If i give up on this because i can't get it sorted out, then I guess we can let him try it next
but i can't have 2 people on it at once and there is no point laying out money for a second one
im not yet convinced the first one was worth it all
(This post was last modified: 06-04-2014 02:54 PM by ShelaghDB.)
06-04-2014 02:52 PM
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robysue Online
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Other Comments: Papping since September 2010

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Location: Buffalo, NY

Post: #7
RE: Finally got the Hubbies Info. Can someone please advise?
ShelaghDB,

What was hubby's AHI on the diagnostic test? I know you describe it as "borderline"---but "borderline" is in the eyes of the beholder. Is hubby's diagnostic AHI between 5 and 10? Or is it between 10 and 15? And how symptomatic is hubby in terms of daytime fatigue or daytime sleepiness?

Regardless, if hubby slept all night during the original diagnostic sleep test, it shouldn't matter that much if he sleep on his back or not. Here in the states, many techs insist that you try to get some sleep on your back even if you swear to them that you never sleep on your back. The rationale is that for the vast majority of people with apnea, the apnea is at least as bad on the back as it is in any other position AND for a significant number of OSA sufferers, the OSA is substantially worse when the person is sleeping on their back.

But the numbers you posted for hubby's titration study do indeed lead to the conclusion that this was a "failed titration study" since the tech could not find a pressure that worked.

Even though I know you don't like the doc, I do think there are some things that only he might be able to clarify:

1) The tech titrated hubby only as far as 12 cm. Even though hubby's OSA is mild, it's possible that he needs more pressure than that to really control the OSA. If another titration study is done, would the idea be to start hubby out at a pressure that's higher than 5 cm??? How much higher than 5 cm?

2) There are 7 central apneas scored during the titration test, but from the information you've been given there's no way to figure out when those centrals happened. It's relevant to know whether there were any centrals on the diagnostic test. It's also relevant to know whether the centrals on the titration study happened at relatively low pressures or relatively high pressures. It's also relevant to know whether the 7 centrals were clustered close together or spread pretty far apart. Chances are the doc won't treat this concern seriously simply because the number of CAs is so small for the entire night. Still if every single one of the CAs occurred after the pressure was raised to 9 cm, that may be important.

3) Hubby's AHI does seem substantially higher at pressures that are above 9cm. And the problem is not that hubby was asleep for only a few minutes at a given pressure before 2 or 3 events occurred and the tech increased the pressure. Rather: It appears that hubby spent at least 20 minutes at each pressure that was tried, and for every pressure other than 11cm, it looks like hubby slept at least 35 minutes or more. So it's reasonable to wonder: Do some of the numerous hypopneas have a central component? Or are they all obstructive---but then why weren't they present in these kinds of numbers on the diagnostic sleep test?

As for whether hubby "belongs" on CPAP or not: Given the fact that his AHI was over 20 at 9, 11, and 12 cm, something counter-intuitive is going on here. An untreated AHI = 20 is definitely considered to be moderate OSA and here in the states, that guarantees that the docs will tell you that you absolutely MUST try CPAP. So if a patient goes from an untreated AHI = 10ish to a treated AHI = 20ish on PAP, then clearly PAP is not really working for that particular patient.

With hubby's combination of a BMI = 40+ AND borderline untreated OSA AND a dramatic rise in AHI on the CPAP titration trial, it is reasonable to consider another titration study and/or alternative treatments.
06-04-2014 03:08 PM
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robysue Online
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Post: #8
RE: Finally got the Hubbies Info. Can someone please advise?
(06-04-2014 02:20 PM)ShelaghDB Wrote:  I am not sure if he is borderline...i really don't know what this means and for that matter WHY he would not have been able to have got a proper test result for I KNOW he slept all night LOL
On a diagnostic sleep test (one without a mask) the usual cutoffs are:
  • 0 <= AHI < 5. The test is considered normal for sleep apnea and the patient is NOT diagnosed with OSA (or any other version of sleep apnea).
  • 5 <= AHI < 15. The patient is diagnosed with mild sleep apnea. Borderline usually means he untreated AHI is pretty close to 5. Here in the states, most insurance companies are willing to pay for a CPAP for a person with mild sleep apnea if the person has daytime symptoms that are affecting the quality of their life. Many docs will leave the final decision about whether to try PAP up to the patient, and the patient won't be lectured at if they choose to NOT do PAP.
  • 15 <= AHI < 30. The patient is diagnosed with moderate sleep apnea. Here in the states, you'll be told by the doc that you absolutely MUST start CPAP therapy. Insurance companies will not require the doc to document that the person has daytime symptoms; they'll pay for the machine as long as the patient meets compliance requirements. If the patient has a very difficult time adjusting, the doc may very well suggest alternative therapies, including oral appliances.
  • AHI => 30. The patient is diagnosed with severe sleep apnea. Here in the states, you'll be told by the doc that you absolutely MUST start CPAP therapy. Insurance companies will not require the doc to document that the person has daytime symptoms; they'll pay for the machine as long as the patient meets compliance requirements. If the patient has a very difficult time adjusting, the doc will keep reiterating that they need to figure out a way to make PAP therapy work. As a last resort, the doc may agree to an alternate therapy, but the insurance company may not be willing to pay for an oral appliance.

Quote:I was up early and we ere the only 2 people there and I know he slept perfectly through the night and the woman that was testing us and I were talking, waiting for him to get up and she told me he slept all night so why they could not get proper tests from that IF this is what this means, I can't imagine.
If you're talking about the diagnostic test, there's no reason they shouldn't be able to call the test a success.

If you're talking about the titration test, the test was a failure because the tech couldn't find a pressure setting that worked even though hubby slept soundly all night long.
06-04-2014 03:22 PM
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robysue Online
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Machine: PR Dreamstation BiPAP Auto
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CPAP Pressure: min EPAP = 4; max IPAP = 9;
CPAP Software: SleepyHead EncoreBasic EncorePro

Other Comments: Papping since September 2010

Sex: Female
Location: Buffalo, NY

Post: #9
RE: Finally got the Hubbies Info. Can someone please advise?
(06-04-2014 02:52 PM)ShelaghDB Wrote:  
Quote:CMS50x oximeter

So to do a Titration when you don't know where to begin for someone, is done, how?
I think the idea is that you gather the oximeter data at the same time that you're titrating on the AutoSet. SleepyHead can import the data from both devices.

Where to start? For simplicity I wouldn't really bother with the oximeter right now. It's another piece of equipment to buy and use.

If hubby is willing to try PAP and you can get your hands on an AutoSet (or a PR System One AUTO), then here's how you can start doing the titration:

Start with the machine pretty wide open, but with the min pressure high enough to be comfortable for hubby. I'd suggest setting that min pressure at 5 or 6 since he had no trouble falling asleep at 5 cm with the mask in the lab. Leave the top pressure open for the first week or so.

Look at the data everyday. The major thing you're looking for is whether or not you see the same kind of trend that is apparent in the sleep lab's data: If hubby's AHI goes UP when the pressure is above 9 or 10 cm, then you know there's some kind of problem using higher pressure settings. If hubby's AHI does NOT go up when the pressure is above 9, you'll know that the night in the lab was some kind of freaky outlier.

After a week or so you want to look at the following data pretty carefully:

The median and 95% pressure levels.
The AHI
The OAI
The HI
The CAI
The median and 95% leak numbers.

Also look at the graphs for each of the seven days.

If his AHI does NOT seem to get worse when the pressure is at or above 9cm, then you can pretty much conclude that his pressure needs are probably pretty close to that 95% pressure setting. And you can then reset the min pressure setting to be about 1-2 cm below that 95% pressure setting and the max setting to be about 1-2 cm above that pressure setting. And run the machine with the new settings for a week or two. If the AHI by the end of that time is pretty consistently well below 5 and hubby is feeling better, you know you've found a good setting.

The sticky thing is: What to do if the AutoSet numbers look like the in-lab titration numbers? In other words, the hard thing you might face is what to do if hubby's AHI remains high after a week of autotitration? Or what if hubby starts having significant numbers of events everytime the S9 raises the pressure above 9 or 10 cm? And that's another whole can of worms. If that happens, then you're basically back to square one and you need to consult with a sleep doc. And if hubby's untreated OSA really is mild, but PAP therapy is triggering enough additional (presumably central) events to push him into the moderate sleep apnea category, then hubby may very well be better off doing the serious work to lose the necessary weight and keep it off. And be retested without a PAP about six months after he's taken the weight off and kept it off to see if the weight loss was really all he needed to do.

Quote:And once you determine the area of pressure that is right for him......you then bring an oximeter into it?
Ive not been told that myself by anyone else yet so I am at present not even sure what that means.......how much it costs OR, what makes that, make this S9 AutoSet a complete sleep study, whereas without this oximeter, it doesn't?
No. Adding the oximeter to the AutoSet does NOT make using an AutoSet "a complete" sleep study. But it does give additional information about whether the person is continuing to have significant O2 desaturations while sleeping. And on an in-lab sleep test, that O2 data is used to help score real hypopneas, which require more than just a decrease in airflow that lasts 10 seconds. There either needs to be an associate O2 drop or an EEG arousal for a hypopnea to be scored on a sleep test. To have a full sleep study, there has to be ways to track the following data:
  • Effort to breath. During an in-lab sleep test, that's what the belts are for. While the S9 can use its FOT algorithm as a proxy for determining the difference between CAs and OAs, it is important to remember that it is a proxy algorithm. From what I've been able to learn, the S9 FOT CA/OA detection algorithm is reasonably decent in the sense that if an event is scored as a CA, it probably was a real central apnea. But if a person is having a lot of real central apneas, then some of those apneas are likely to be mis-scored as OAs or Hs by the S9's Auto algorithm. And since hubby's AHI increased rather than decreased when he was put on PAP, you have to be at least a bit concerned that he may be sensitive to pressure and have problems with pressure induced centrals. And you can't rely totally on the S9 to tell you that the additional events are Central Apneas or Central Hypopneas.
  • EEG data and muscle movement detection around eyes and jaw. This data is used to determine when the patient is asleep and when the patient is awake. This data also is critical for determining the sleep stage. And microarousals. It looks like hubby's titration study used Rule 4B for scoring the hypopneas; that means that an O2 desat was NOT required for a hypopnea to be scored; an associated EEG arousal was all that was needed. Now, as long as hubby sleeps reasonably well with mask, you can kind of assume that he's asleep most of the time the machine is on. Hence you can assume that most of the events are indeed real. But you can't determine when he's in REM vs non-REM and you have no way to measure arousals that are not related to respiratory events picked up by the AutoSet.

Quote:So I will assume no one is able to make out IF he has sleep apnea or not? LOL
You need to request the copy of the diagnostic sleep study. The titration study is not the same thing.

And here's the thing: The AHI = 5 is in some sense an artificial line drawn in the sand to determine which patients get diagnosed and which don't. But for people right near the border? Some nights their untreated AHI may be as high as 6 or 7 and some nights their untreated AHI may be as low as 3 or 4. It's not uncommon for the AHI to fluctuate a bit from day to day. And so whether they wind up with an official diagnosis after the first test may depend (strongly) on what night the test was done.

To draw an analogy: OSA is kind of like high blood pressure. Some people clearly have high blood pressure because their (untreated) readings are ALWAYS high. Some people clearly don't have high blood pressure because their blood pressures are NEVER high. And some people are in the middle with "borderline" high blood pressure problems---sometimes it's a bit too high and sometimes it's just below the "cut-off" for high blood pressure. And whether to treat a particular individual who has "borderline" high blood pressure is ultimately a decision that is made on an individual basis.

The same thing is true for folks who are on the borderline of an OSA diagnosis; the decision whether to treat or not treat is not as simple as you might expect, and it needs to be tailored to the particular borderline OSA patient's full medical history: If the person has symptoms, then many docs and insurance companies will be willing to let the person try PAP if they want to. If the person is NOT symptomatic, though, the docs are not as likely to push the person into PAP as you might think. And the rationale for not pushing PAP onto a borderline OSA patient who has no symptoms is not silly: PAP can be highly disruptive of some patient's sleep, is a rather expensive therapy to pursue, and for people with very mild OSA and no daytime symptoms there are no scientific studies that show any real medical benefit to using PAP.

But there ARE studies that show that if a person with very mild sleep apnea has daytime symptoms, then PAP will do a good job of reducing or eliminating the daytime symptoms---if a quality titration can be done and appropriate pressure level can be determined. And ultimately that's why many sleep docs leave the choice of whether to PAP up to the patient when the patient has been diagnosed with borderline OSA.

Quote:In any event he does not have an AutoSet.
So a self-titration (for now) is kind of a moot point?
06-04-2014 04:14 PM
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bwexler Offline

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Machine: PRS 1 BiPAP autoSV Advanced, with Heated Tube humidifier
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Mask Make & Model: Sleepweaver Élan
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CPAP Pressure: Max pressure 25.0 cm H20, Max
CPAP Software: SleepyHead EncorePro

Other Comments: CMS 50i with Software for SpO2

Sex: Male
Location: San Marcos, CA, USA

Post: #10
RE: Finally got the Hubbies Info. Can someone please advise?
Quote:
In any event he does not have an AutoSet.

What machine does he have?
What are your settings and would you be willing to trade machines for a few weeks while testing and adjusting his needs?

RobySue said what I meant much better than I ever could.
The oximeter is simply another tool in your tool box to help verify what you see in your reports.

If you are driving your car and the speedometer says 60 MPH and you also happen to have a GPS which says you are going 60, then you use a stop watch to see how long it takes to drive from one mile post to the next and it takes 60 seconds, you have verified the accuracy of your speed. If the three disagree you need to check which is in error and adjust your driving habits to avoid tickets.
06-04-2014 05:02 PM
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