Hello Guest, Welcome to Apnea Board !
As a guest, you are limited to certain areas of the board and there are some features you can't use.
To post a message, you must create a free account using a valid email address.

or Create an Account


New Posts   Today's Posts

[Pressure] Help for a newbie: titration failed
#21
RE: Help for a newbie: titration failed
Okay, I have another question. During my CPAP titration, my AHI began to drop at 11 cmw. It started at 24 and eventually went all the way down to 15 until they stopped the study at 17 cmw. Given that my initial AHI was 56.5, a drop to 15 is good, right? Is it likely to drop further as I approach a pressure of 25 cmw? What are the chances I'll get below 5? I also noticed that once I got up to 11 cmw, my O2 never dropped below 92. I know this is all speculation and I won't know anything for sure until I complete my bilevel titration, but I'm still trying to wrap my head around how sleep apnea works and I'm not quite there yet.

I saw someone use the analogy here that an AHI of 15 is like somebody poking you with a stick every four minutes, which I think is hilarious. But, if I had to choose, I'd take once every 4 minutes over every minute.
Post Reply Post Reply






Donate to Apnea Board  
#22
RE: Help for a newbie: titration failed
AHI of 5 is the medical marker to state it's treated. I have had the AHI at 0-3 for about 3 years on my ASV until COPD threw a wrench in the works. My original sleep study had 78 or so AHI. So if you meant 15 AHI there's more work needed. It depends highly on the right machine and right settings being in play.

See how much doc likes being shaken or choked every 4 minutes for 8 hours. Then ask "how'd you sleep?". Mornincoffee
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
Post Reply Post Reply
#23
RE: Help for a newbie: titration failed
Quote:pap machines, resmed at least, increase pressure against plm induced flow limitations

There is no such thing as a "plm induced flow limitation" - respiratory disturbances can induce PLMs, but not vice versa. A biological urge to move the legs doesn't magically cause the pharynx to become more collapsible. The phenomenon of flow limitations leading to arousals that include PLMs however is well documented in the literature.
Post Reply Post Reply
#24
RE: Help for a newbie: titration failed
well, I guess we disagree about this one, Illorum.  I agree that respiratory disturbances cause restlessness and the 'thrashing' movements I used to experience during the struggle to breathe before cpap.  otoh, I'm not inclined to believe respiratory disturbances cause periodic limb movement simply because plm is necessarily 'periodic' and respiratory disturbances rarely are.  I've also become aware that the 'jolts' that I feel during waking restless legs (I can have plm without rls but plm always follows rls) begin at the base of my spine and have nothing whatsoever to do with breathing disturbances.  take a look at the screenshot.  note the relatively abbreviated breaths between spikes that coincide with plm kicks. these may be unflagged flow limitations. in addition, the dark spots below the line are moans/groans which are most certainly non-passive flow limitations that, like chin tucking, can't be overcome with cpap pressure.  with apap I frequently had runaway pressure as a result of plm.  with asv, pressure support would swing wildly following the plm flow rate pattern like the one in this screenshot.  with vauto, I'm able to maintain ps (unlike apap), but cap the max ipap more effectively than with asv.


Attached Files Thumbnail(s)
   
Post Reply Post Reply






Donate to Apnea Board  
#25
RE: Help for a newbie: titration failed
Can someone please break this down for me?


PAP Titration Study Report

Date of Study: 12/6/2020
Age: 44 (DOB: 8/4/1976) ESS: 6/24 Neck Circ. (cm): 37.0
Height (cm): 167.6 Weight (kg): 87.3 BMI: 31.1

Sleep history: The patient is a 44 year old female with obstructive sleep
apnea. A split study on 11/24/2020 showed an overall apnea-hypopnea index
(AHI) of 56.5, Supine AHI of 56.5, and an oxygen saturation nadir of 86%. No
adequate pressure was obtained during CPAP titration. Here for BiPAP
titration study. The patient is not using CPAP at home. The patient endorses
being a habitual side sleeper. During the study, patient was sleeping on at
least 3 pillows, at about 45 degrees incline.
Sleep procedure: PSG w/CPAP or Bilevel PAP 4 or > param PC (95811)

Procedure: The study was attended continuously by a sleep technologist. The
monitored parameters included: left (E1-M2) and right (E2-M1) EOG, frontal
(F3-M2 & F4-M1), central (C3-M2 & C4-M1) and occipital (O1-M2 & O2-M1) EEG,
mental and submental EMG, left and right anterior tibialis EMG, single ECG
waveform, snoring, continuous airflow via PAP interface, chest and abdominal
effort, oxygen saturation, and body position via video monitoring.

Hypopnea definition: The peak signal excursions drop by = 30% of pre-event
baseline using nasal pressure (diagnostic study), PAP device flow (titration
study) or an alternative hypopnea sensor (diagnostic study). The duration of
the = 30% drop in signal excursion is = 10 seconds. There is a greater than
or equal to 4% oxygen desaturation from pre-event baseline.
Respiratory Effort Related Arousal (RERA) definition: 10 seconds
characterized by increasing respiratory effort or by flattening of the nasal
pressure or PAP flow waveform leading to arousal from sleep when the sequence
of breaths does not meet criteria for an apnea or hypopnea.
Respiratory Disturbance Index (RDI) definition: RDI = (#apneas + #hypopneas +
#RERAs) x 60 / TST. If AHI is 0.0, then RDI = RERA index.

SLEEP ARCHITECTURE:
The study started at 22:02:47 and ended at 04:46:40. Total sleep time (TST)
was 309 minutes resulting in a sleep efficiency of 77.0% (total recording
time (TRT) = 401 m). There were 21 awakenings with a total time awake after
sleep onset of 62.0 minutes. The sleep latency was 28.0 minutes and the REM
latency was 164 minutes. The patient spent 93.0% of sleep time in the supine
position. The sleep stage percentages were 11.0% stage N1, 67.5% stage N2,
6.1% stage N3 and 15.4% REM sleep. There were 125 arousals, resulting in an
arousal index of 24.3. There were 95 stage shifts.

POSITIVE AIRWAY PRESSURE DATA:
Bilevel was initiated at 12/7 cmH2O. Snoring was not eliminated. There were
67 respiratory events consisting of 25 apneas [23 obstructive (92%), 1 mixed
(4%), and 1 central (4%)], 8 hypopneas and 34 RERAs. The mean oxygen
saturation during the study was 96%, with a minimum oxygen saturation of 91%.
The patient spent 0.1% (0.3 min) of sleep time with an oxygen saturation
below 90% and 0.1% (0.3 min) of sleep time with an oxygen saturation at or
below 88%. Cheyne-Stokes/Periodic Breathing was not present. Supplemental
oxygen was not administered. A small ResMed Mirage Quattro full face mask
without chin strap was used. The mask leak at the most effective pressure was
within normal limits.

PAP SUMMARY:
By Pressure:

PPAP     TST     %Sup   SupAHI  REM     RAHI     CAI     AHI     Arldx     SupRDI     RRDI     HI      Nadir   AvgSaO2
12/7      31         5          7.5        0          0          0      5.8      32.9       37.5          3.9     21.3     91          95
13/7      66         90        11.1      0          0        0.9     11.8    30.9       24.2          3.6     25.5     92          96
14/8      57.5     100        8.3      20.5     5.9         0      8.3      23         13.6          5.9      1         92          96
15/9      132      100        3.6      27        2.2         0      3.6      13.2       5.9           4.4      0.5      92          96
17/11    22.5     100        2.7        0          0          0      2.7      18.7       5.3              0      5.3      94          96


MOVEMENT DATA:
No abnormal behavior was noted. There were 58 periodic limb movements during
sleep, resulting in a PLM-index of 11.3. Of these, 8 movements were
associated with arousals, resulting in a PLM-arousal index of 1.6.

ECG DATA:
The average heart rate during sleep was 74 beats per minute, with a range of
64 to 85. During wake, the heart rate ranged from 69 to 98 beats per minute.
No arrhythmias were noted.

OTHER NOTABLE FINDINGS:

1. Experience to PAP therapy as stated by the patient on the morning after
sleep questionnaire: The patient feels they did not benefit from PAP therapy,
mask was too tight, air leaked from mask, felt claustrophobic, and it was
easy but uncomfortable to use.

ICSD DIAGNOSIS:
Obstructive Sleep Apnea Syndrome [G47.33]

IMPRESSION:
1. At a PAP setting of 15/9cmH2O, during which supine REM sleep was recorded,
the apnea-hypopnea and arousal indices were normalized, snoring was not
eliminated, and the oxygen saturation was maintained above 91%. However, at
this setting the supine RDI is in the mild range, and there were also
frequent airflow limitations noted, also at 17/11, though not qualify for
sleep disordered breathing events per CMS criteria.
2. Abnormal sleep architecture likely due to respiratory events, PAP
titration, medications, and first night effect.

RECOMMENDATIONS:
Auto titrating Bilevel PAP device with humidification: IPAP/MAX 25cmH2O,
EPAP/MIN 9cmH2O, PS 4-6, at about 45 degree incline. A small ResMed Mirage
Quattro full face mask without chin strap was used. The patient may benefit
from a formal mask fitting and education.
Post Reply Post Reply
#26
RE: Help for a newbie: titration failed
Lily, you have persistent obstructive sleep apnea and snoring that seems to reasonably resolve at rather high pressure. My opinion is that your use of pillows to sleep at a 45 degree angle has a lot to do with the persistent obstruction and snoring, and you probably need a soft cervical collar to help with that. In any event, you are about to be prescribed an auto bilevel machine at EPAP min 9.0, IPA max 25 and pressure support of 4 to 6 cm. To me that sounds like a Dreamstation BiPAP Auto. I think you will do better with Resmed Aircurve 10 Vauto which will move pressure faster, but has fixed pressure support. Since you tolerate PS of 6-cm without problems, I would just start you at EPAP min 9.0, PS 6 (15/9) and let the machine do its thing.

I'm not sure what you want broken down out of this sleep titration study. It is almost certain you have a combination of positional apnea as well as treatable obstructive apnea. It would probably help you to read the Positional Apnea wiki http://www.apneaboard.com/wiki/index.php...onal_Apnea to better understand how chin-tucking can result in obstruction, even with high CPAP or BPAP pressure. Also look at the Soft Cervical Collar wiki to see how the use of a collar can clear up this problem, allow lower pressure and improve results. http://www.apneaboard.com/wiki/index.php...cal_Collar Let me just add, your inclined sleeping position with many pillows was a survival tactic before therapy. Once you have the therapy, it will hold you back by making you more prone to positional apnea. You may need some time to transition back to a more "normal" sleep position, but I encourage you to try.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
Post Reply Post Reply
#27
RE: Help for a newbie: titration failed
FWIW I would ditto all this. The guru has it pinned down again as I see it. My 2 cents is on the selection of the machine as Sleeprider has already mentioned. You will need to only accept ResMed's AirCurve 10 VAuto. You can force that to be the choice by a few ways. 1. find out what the DME you're going to be working with intends to issue. Ask for the detailed name, and if it's not this ResMed, state you chose this ResMed. 2. If they state they can't or won't issue ResMed, change the DME. Tell the current one that you're leaving for another DME if they will not honor the ResMed request. 3. is to discuss with your prescribing doc that you want ResMed (full name needed as above) and that you want doc to add it to the script with mask of patient choice, and to DAW/dispense as written. DAW negates substitutions. Or it should. Be certain the machine you do get and sign for is exactly what you want. If not, refuse it. It's far harder to get machines changed AFTER you accept. Also do not give the DME your bank or credit/debit card info. It is not required, and if you do give it, some DMEs are shady enough to bill you and insurance for the same bill. Or they will attempt to make you pay what the insurance agreed upon contract does not cover.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
Post Reply Post Reply






Donate to Apnea Board  
#28
RE: Help for a newbie: titration failed
I want to bang my very sleepy head against a wall.

My PCP, without asking for my approval, ordered a bilevel PAP machine from the Home Care Services department of the major regional hospital (think Mayo Clinic) where I am seen. The Home Care Services department, by the way, has a 1.9 star rating on Google.

I did not like this one bit, but PCP does not appear to like being questioned by patients. The best I could to was to ask her to mail me a copy of my PAP script "for my records."

I then called Home Care Services and asked if I had any choice of brand.

"No, we only carry Respironics machines. We'll call you in about a week to arrange delivery." They made no mention of a mask fitting.

I hung up and called three DMEs that are covered by my insurance. All carry ResMed machines. I asked if I could schedule an appointment for an intake (thinking the script has to be here soon, as it was mailed a week and a half ago). I figured I could make an appointment and show up with my copy of the script in hand.

"No," they told me. "You're doctor's office needs to fax us your prescription before you can make an appointment."

Meanwhile I contacted the doctor's office to see what the holdup with the script is. "Oh, that's going to take some time," I was told. "It has to go from here to Main Campus and then to you. If you're going to need it soon you have to come pick it up." (Would have been nice to know that BEFORE they mailed it.)

So I am stuck in a hell of Catch-22. I literally do not know what to do next, so I called Home Care Services and asked them to put my BiPAP order "on hold" so that at least they won't try to bill my insurance for it.

I have an appointment with a nurse-practitioner in Sleep Medicine in a month (I took the first appointment they had). If I am lucky, perhaps they will agree to fax my script to the DME and I will be able to start PAP therapy by early February. Yay.
Post Reply Post Reply
#29
RE: Help for a newbie: titration failed
I respectfully suggest firing PCP if you can do so while hiring new PCP at same time, I'm quite serious as this is an action I'd do myself if what you're stating happened to me, doc that orders stuff from place I don't approve or have part in decision is part of my firing reason, other half is doc doesn't like you to have questions about your care. Fire 'em.

To help you understand how your situ is related to my PAP care to NIV: I had phone consult this past Tues. with Dr. Jablin, he's to probably be my new pulmonary doc, not now though he's fired after that FIRST and only consult via phone. Phone part is not considered reasoning, but this "doctor's" comments are exactly why he won't be supporting my pulmonary needs. He told me I haven't the medical training to read my sleep studies and titration reports, so my stating info like apnea event count and type such as seeing Central Apnea events at 124 times is irrelevant because I read it to him, I'm not allowed to question that or him as THE DOCTOR??? I have been told by this quack that I do not have COPD due to most recent PFT/pulmonary function test report states a reduction in COPD negative affects as last PFT so that means to him I don't have COPD, WHAT!? Further, since a titration done by my previous pulmonary office reported 0 AHI I don't have any apnea. You do realize a titration is whilst on a PAP and a mask, and therapy is being applied doc? You're not medically trained so you have no idea what you're saying. About oxygen levels doc. I'm monitoring my oxy levels as it seems my heart condition PVC is causing high irregular heartbeats and my oxy level falls to 80 something % at times. Condescending toned doc "Your oxygen level is dropping is false, you are looking at a pulse oximeter which I don't recommend and looking at the data causes artifacts of false readings, meaning when you look at the oximeter, it causes the oxygen levels to drop." Not verbatim but close enough. Note that this phone style consult is important in one way I think. He or his nurse did not take my pulse oxy reading as normally would happen, nor has he ever done any physical examination of any sort on any of my medical conditions, again I state never looked at me. This all is signs of a QUACK a sham a doc that should not be employed. I mention this as my basis to say this, looking at my real statement of what an actual doctor told me, again not verbatim, but the gist is there and real. I feel your PCP sounds similar. Am I close to being correct in assessment? If yes or even close, do yourself a big favor and fire that overinflated ego that calls himself doctor and replace him ASAP.

Important thing 2 call this Home Care Services and tell them not to bother shipping machine unless you 100% WANT the machine they are allowing a choice of 1. Fire and replace also.

And call that Quack doc's office DAILY, the one that supposedly sent your script, ask daily on phone where is the script? Demand it be re-sent, or in other form, can you accept fax and will they send fax? or something, you must demand attention, answers, and action NOW. I am in the process of doing similar things regarding my pulmonary and I am not suggesting you act in a way I'd not do myself.

I am concerned that it'll take till Feb. for you to begin PAP therapy. Why the delay? That too is borderline not acceptable to Dave if it were Dave. Even if they have to order a PAP why the 2 month delay. Question then refuse and replace with new entity that gives PAP ASAP.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
Post Reply Post Reply
#30
RE: Help for a newbie: titration failed
I have my very first appointment with a Sleep Medicine RN tomorrow after being diagnosed with OSA on Nov. 24. Are there any questions I should be sure to ask? My doctor (surprise, surprise) gave me a hard time about my PS settings. She wrote the script for 4 when the interpreting physician recommended a pressure of 15/9, so I will be asking about that.

Also, fingers crossed, I *might* be getting my machine (AirCurve 10 VAuto, which I fought like HELL for) this week. I have two questions:

1. I told the respiratory therapist at the DME that I would like to try a hybrid-style mask like the AirFit F30i since the two FFMs I tried during my titration studies were *excruciatingly* painful. He told me, "I don't think that's the best choice. I like the F20 better." I was tempted to retort, "I don't care what you like; I'm the one who will be wearing it!!!" but I held my tongue as he has been MUCH nicer and more helpful than my idiot doctor. I cannot try on masks due to Covid, obviously, but he offered to measure me to ensure fit. I am very suspicious of a traditional FFM because the ones I tried (F&P Simplus, medium, and Quattro Mirage, small) cut into the skin of my cheek in the exact same place. The RT recommended trying the F20 and exchanging it if I don't like it. How hard should I fight to be sent home with an F30?

2. Aside from downloading OSCAR (already done) and making sure there is an SD card in the machine, is there anything I should do to prepare for my first night of therapy? I do plan to wear it during the day a bit to get used to it.

P.S. I know not to give the DME my credit card number, and I will NOT be signing anything until I understand and am happy with what I am being given!

Thank you, everyone!
Post Reply Post Reply






Donate to Apnea Board  


Possibly Related Threads...
Thread Author Replies Views Last Post
  Newbie Needs Help Please CanMFT 16 306 12-30-2020, 12:14 PM
Last Post: Dormeo
  [Pressure] Is Titration Recommended? Remember2Breathe 9 228 12-28-2020, 09:42 PM
Last Post: Remember2Breathe
  Newbie help interpreting data and having settings nickng33 6 198 12-15-2020, 11:20 PM
Last Post: SarcasticDave94
  After Four Failed Machines it is Clear - RESMED SUCKS Akhenaten33 7 412 11-18-2020, 10:56 PM
Last Post: SuperSleeper
  [Equipment] Has Your Philips Dreamstation Humidifier Lid Latch Failed? FLsleeper7 22 3,774 11-10-2020, 12:34 AM
Last Post: ewjohnson
  Newbie looking for a clue mike291068 47 2,536 10-25-2020, 01:30 AM
Last Post: jaswilliams
  [CPAP] Newbie would like some advice (Aircurve 10 VAuto) leancomfort 8 367 10-19-2020, 04:48 PM
Last Post: leancomfort


New Posts   Today's Posts






About Apnea Board

Apnea Board is an educational web site designed to empower Sleep Apnea patients.