New to Apnea Board & SH, would you review screenshot please?

[Sleeprider]

I think you might do well with bilevel therapy. With the number of events still mainly obstructive, the advise for higher pressure has been correct. You will find higher pressure more tolerable with bilevel. Your obstructive apnea is fairly consistent through the night so positional therapy using a cervical collar is not likely to be effective, but if you do sleep in a way that causes your chin to drop to your chest, it could make a difference.

[halokittie]

Put in a new SD card yesterday so data from last night attached. Pressure was upped to 15cm.  

I do start out on my back at night, but usually end up on my left side sometime during the night, so not sure how that affects things. 

Thanks

[Walla Walla]

Well I'd bump the minimum up to 17cm. If that doesn't do it than I think Sleeprider is right about needing a BPAP.

[Gideon]

I'll point out that CPAP pressures of 15+ is criteria of some titration protocols to try BiPAP/BiLevel titration.

Fred

[halokittie]

Original poster here.  I had a bilevel titration study done in February, saw the sleep doctor yesterday for the review.  He felt that I did well in the study with higher pressure and that I should continue with the Phillips Respironics Dreamstation APAP with a low of 19 and high of 20, with a ramp from 15 if starting at 19 proved uncomfortable.  

I changed the minimum pressure myself (no telling how long the DME would take), and 19 was not uncomfortable for me at all.  No need to ramp up, did not have any leaks that I could tell.  It didn't make a difference in how I felt in the morning, though that may be asking for too much in one night.  

The sleep study and last night's Sleepyhead chart are attached.  Would you please review and let me know what you think?

[Sleeprider]

Your doctor decided it's okay that you have central apnea from the use of CPAP at 19 cm pressure and desaturations to 85% because you accomplished REM sleep and seemed to tolerate it?

Your doctor is a duck. His last note is that if your oximetry shows you don't maintain O2 or you don't tolerate these ridiculous CPAP pressures, he will finally grat you the bilevel titration he should have switched to when you passed 15 cm. What kind of sadistic ass is he?

This comes down to you. If you're comfortable, and if you're going to tolerate this abusive pressure and lack of efficacy asn shown by the titration study, then that is just fine. Otherwise, your doctor has already stated he will do a bilevel titration. Tell him in no uncertain terms that you are extremely uncomfortable, and want to move on to bilevel. What strikes me as odd, is that the doctor told you he was going to do a bilevel titration. In your first post you indicated he had told you he though there was enough evidence to proceed with bilevel evaluation. Why he ended up with CPAP then clearly made a bad judgement call that you should just continue with CPAP at 19-20, even though it didn't work, is bizarre.

[ajack]

Before I got another machine, I'd try a $10 foam cervical collar to see if my airway is straight all night. It will be a lot better trying to fix this and getting a lower pressure needed.
If you still have these pressures, you are going to need another machine. You may be best seeking another opinion, if at your next appointment he doesn't have ideas to fix it with another titration and machine.

[halokittie]

Your doctor decided it's okay that you have central apnea from the use of CPAP at 19 cm pressure and desaturations to 85% because you accomplished REM sleep and seemed to tolerate it?  

Your doctor is a duck.  His last note is that if your oximetry shows you don't maintain O2 or you don't tolerate these ridiculous CPAP pressures, he will finally grat you the bilevel titration he should have switched to when you passed 15 cm.  What kind of sadistic ass is he?

This comes down to you.  If you're comfortable, and if you're going to tolerate this abusive pressure and lack of efficacy asn shown by the titration study, then that is just fine.  Otherwise, your doctor has already stated he will do a bilevel titration.  Tell him in no uncertain terms that you are extremely uncomfortable, and want to move on to bilevel.  What strikes me as odd, is that the doctor told you he was going to do a bilevel titration.  In your first post you indicated he had told you he though there was enough evidence to proceed with bilevel evaluation.  Why he ended up with CPAP then clearly made a bad judgement call that you should just continue with CPAP at 19-20, even though it didn't work, is bizarre.

Sleeprider, thanks for putting it so succinctly.  I was so taken aback when I saw the doctor on Monday that I had a hard time pulling my thoughts together.   I was certain that I was to have a "bilevel titration", not another "sleep study" based on his words during my February appointment.  He described how a bilevel machine functioned and stated that it was fortunate that I was on Medicare because the then current documentation and the titration would be enough to get a bilevel machine approved through Medicare.  

Then on Monday he was all just, everything looks good at higher pressure in this "sleep study" and we'll call the DME to change the pressure and if it's too much let us know and do you need a refill of Nuvigil and see you back in a month.  Did not address the centrals or desats at all.

At any rate, I tried a 2nd night at 19-20 but woke up three hours in with completely blocked nasal passages. Haven't had that happen before. 

Here's my plan til my next appointment:
1) Dial back my pressures to 15/20 
2) Track my O2 with a pulse oximeter
3) Post sleepyhead charts here for review and comments
4) Advocate strongly for a bilevel machine 
5) Get a 2nd opinion


What do you think?

[halokittie]

Before I got another machine, I'd try a $10 foam cervical collar to see if my airway is straight all night. It will be a lot better trying to fix this and getting a lower pressure needed.
If you still have these pressures, you are going to need another machine. You may be best seeking another opinion, if at your next appointment he doesn't have ideas to fix it with another titration and machine.

Thanks ajack.  I tried the cervical collar, but I'm really short and even a pediatric collar pushed my chin too far up.  No way I could fall asleep in one.

[Sleeprider]

Halokittie, unless I'm getting something terribly wrong, the second section of your sleep study shows you were titrated from 10 to 19 cm pressure. Following sleep onset at 22:05 you had zero AHI at 10, 11 and 12 cm pressure. At a pressure of about 14, your AHI spiked to 7.5 and dropped back to zero at 15-16 cm. As pressure got higher from there, your AHI increased and your desaturations were worse. It appears that "success" was you experiencing a REM cycle, regardless of the respiratory distress the pressure caused. They actually induced central apnea and desaturated you to 85% at 19 cm.

Your study was done flat wrong. I wouldn't trust the tech or the doctor as far as I could toss them. You have a zero AHI between 10 and 14 cm, and that is where I would set the machine! Let us help you from there using the Sleepyhead charts. I think you may benefit from bilevel if you truly need these high pressures, but this study was incompetently conducted and interpreted. Drop your pressure and give us the data. We can help. I think it is a shame that not only was this study botched, but the doctor was not even clear on what kind of study would be conducted, or what the objectives of the study would be. I have seen many many studies, and have rarely felt so strongly that the person performing this one should never do another.

I think what I'm seeing here is that your apnea events can be treated at very low pressures. You do have some flow limitations and non-apnea events that may be disruptive to your sleep and therefore keep you from progressing in sleep stage to REM. These respiratory disturbance events (RDI) are frequently very easily treated with bilevel pressures. I could see you needing a very very low exhale (EPAP) pressure such as 8.0 cm, and with some pressure support, completely eliminate these problems. I will go so far as to predict that a competent doctor might be able to titrate you to bilevel, meeting all AHI/RDI objectives, and REM sleep with pressures ranging from 12/8 to 14/10 (IPAP/EPAP). I want you to understand that you do NOT need high pressure to treat your condition because you don't have persistent obstructive apnea, even at lower pressures. You may have some flow limitations and snores that would be very very receptive to bilevel pressures. Your current doctor may be able to get you there, but I have to say, I have very diminished expectations for his abilities after seeing your tests.

edit to note, I am not a doctor or professional, and my opinions are my own.