Questions to ask between at-home study and consult visit?

[Trader Joe]

Hello! I am currently in the early stages of diagnosis and would appreciate some input.

I recently completed an at-home study that revealed an AHI of 101.4, including 182 obstructive, 9 central, 14 mixed, and 69 hypoapneas and 1391 snoring events in a window of 3 hours and 43 minutes. My saturation  was as low as 74%. Other data is included in the attachment. I do not have any OSCAR data nor any additional charts nor graphs.

From there I was diagnosed with severe obstructive sleep apnea and was recommended for "treatment with auto-pap with heated humidication, pressure between 4 and 20..."

This was completed through my primary care physician. Considering the diagnosis modifier of "severe" I am scheduling a  consult with a sleep medicine physician. We have a few in town with fellowship educations and my thought is that one would better be able to treat me. Secondary to that, I'm curious if I might have other issues that a sleep physician would better be able to diagnose. So that leads off my questions:

1) What do I need to know ahead of my consult visit?

2) Should I push for or against a lab study? Is there enough info to diagnose or is it prudent for a more advanced lab study? Asking because report showed central and mixed apneas and I'm unsure if those are enough to be statistically significant.

3) If needing to do a lab sleep study, it could be several weeks before authorizations, etc are approved and I can be scheduled. Would you recommend pushing to starting any therapy sooner? Or would I be undermining purpose of the study potentially finding something else to treat?

4) From at home results, are there any questions you'd recommend asking the physician?

Thank you!

[staceyburke]

There will even others commenting on this I’m sure. MY take is that you should try and get bi level machine. The best one out there is a ResMed s10 aircurve VAUTO. Do not accept a Phillips dreamstation. Your supplier will probably push that brand because they make more off of it.

[Melman]

Welcome to the forum. The specialist may help you but don't count on it. I saw a board certified sleep specialist but didn't get my apnea well controlled until I followed advice from this forum. He didn't seem at all interested in data or to really now much about CPAP therapy.

The most important step is to get the best machine for obstructive sleep apnea which is the Resmed airsense 10 autoset or  Resmed airsense 10 autoset for her. There are several Resmed Airsense 10 models. Be sure you get your doctor to prescribe an autoset model and state dispenseas written. Otherwise the equipment supplier may try to give you a model with fewer features. They are reimbursed the same amount for each of the Resmed models so they make more profit by supplying the least expensive machine with the fewest features. Phillips Respironics makes good machines but the consensus of the most knowledgeable members of the forum is that the Resmed machine provides more effective therapy.

It's possible that you may do better with a bilevel machine but your insurance may not pay for one at this point. The Resmed autoset functions to a limited degree like a bilevel but the amounr of preesure support is limited to 3cm H2O pressure.

It is possible to self titrate and find the best preesure settings with the help of this forum. I had a lab sleep study but the pressure setting recommended based on that study turned  out not to be the most effective. Keep in mind that the lab sleep study is done under unfamiliar and uncomfortable conditions and that one night may not represent the range of apnea experienced at home over a longer period.

[Trader Joe]

I wasn't even thinking about bipap as an option before so that's more to think about. I'm asthmatic but am 35 and don't otherwise have other pulmonary or cardio issues yet, but bipap may be something to consider.

[Gideon]

Welcome to the forum

IMHO
You have without question Severe Obstructive Apnea w 11% Mixed/Central Apnea.  The Central Apnea is a wild card in that we have no idea what is going to happen to the Approximate CAI of 11.  Likely it will go up.  A CPAP / APAP / BiLevel wo Backup is not going to treat the Central portion of your Apnea.  Only an ASV is designed to do that.

Your Oxygen DeSats are also severe.  Don't worry about the low, they typically are, as is yours, for very short periods and as such, insignificant.  The 49% of DSats <= 89% and the 18% of DSats <= 85% are significant.

You were prescribed a, APAP at 4-20 pressures, a very typical prescription.  Adults typically have issues with pressures of 4-5, thus I'd suggest an initial pressure of 7.  This wide-open is in lieu of a formal Titration Study.  I would also suggest a max pressure of 12 be utilized just to eliminate a runaway pressure event right up to 20.  This should be followed up after your first night because This will be the first look at how your body responds to your Apnea.  Because of the number of hypopneas that you have, I would also set EPR = 2 full time.   Now to do this you MUST get a ResMed and not a PR machine, this is critical and on this you do have a choice.

Initial Titration studies almost always result in a prescription for a CPAP/APAP, not a BiLevel, and definitely not an ASV.

What to do moving forward.
IMHO 

1. I would cancel your appointment with the sleep specialist until after we understand the nature of your apnea.  This basically means that we need to determine how significant your Central Apnea is going to be.
   
2. Proceed and get the ResMed AirSense 10 AutoSet, or the AutoSet for Her variant as it has an additional mode. Let us know how you intend to purchase and we will guide you.
   
3. Ensure that you have an SD card any brand, 2-32GB, not bigger (4GB is a great size), this is where your machine will store detailed data
   
4. Set your range to 7-12 cmw, EPR = 2 fulltime.
   
5. Get OSCAR, this will provide detailed data on which to base changes to your setup.
   
6. Post your Nightly OSCAR charts for review in THIS thread after your FIRST NIGHT.  Your settings will need to change, this is normal.
   
7. Revise as suggested, Voice your issues, etc.
   
8. Get a recording oximeter that is compatible with OSCAR, Your Oxygen levels are low enough that I would want to validate that the CPAP/AutoSet corrected your pre-CPAP low O2 levels.
   

Edit
Just read that you are Asthmatic.  I would as the doc to Prescribe the ResMed AirCurve 10 VAuto to support both your OSA and your Asthma.
For the Vauto
Mode=Vauto
Min EPAP =4
Max IPAP =15
PS =4

[Trader Joe]

It is possible to self titrate and find the best preesure settings with the help of this forum. I had a lab sleep study but the pressure setting recommended based on that study turned  out not to be the most effective. Keep in mind that the lab sleep study is done under unfamiliar and uncomfortable conditions and that one night may not represent the range of apnea experienced at home over a longer period.

This is the primary reason I've considered just requesting the Resmed airsense 10 autoset and working with the community in lieu of doing a lab study. I'd love to just get started ASAP but am balancing that with desire to not missing some other underlying issue other than obstructive sleep apnea.

[Gideon]

Read my edited post above

Thanks

[Sleeprider]

I agree Eleuthera Fred’s post and your fastest path to good therapy is to get a Resmed Airsense 10 Autoset and self-titration. In years of coaching members on therapy, very few sleep specialists have been helpful. Just the opposite in fact. Get the machine and get going. That is what insurance will cover and if you need something else , we’ll let you know.

[Trader Joe]

Welcome to the forum

IMHO
You have without question Severe Obstructive Apnea w 11% Mixed/Central Apnea.  The Central Apnea is a wild card in that we have no idea what is going to happen to the Approximate CAI of 11.  Likely it will go up.  A CPAP / APAP / BiLevel wo Backup is not going to treat the Central portion of your Apnea.  Only an ASV is designed to do that.

Your Oxygen DeSats are also severe.  Don't worry about the low, they typically are, as is yours, for very short periods and as such, insignificant.  The 49% of DSats <= 89% and the 18% of DSats <= 85% are significant.

You were prescribed a, APAP at 4-20 pressures, a very typical prescription.  Adults typically have issues with pressures of 4-5, thus I'd suggest an initial pressure of 7.  This wide-open is in lieu of a formal Titration Study.  I would also suggest a max pressure of 12 be utilized just to eliminate a runaway pressure event right up to 20.  This should be followed up after your first night because This will be the first look at how your body responds to your Apnea.  Because of the number of hypopneas that you have, I would also set EPR = 2 full time.   Now to do this you MUST get a ResMed and not a PR machine, this is critical and on this you do have a choice.

Initial Titration studies almost always result in a prescription for a CPAP/APAP, not a BiLevel, and definitely not an ASV.

What to do moving forward.
IMHO 

1. I would cancel your appointment with the sleep specialist until after we understand the nature of your apnea.  This basically means that we need to determine how significant your Central Apnea is going to be.
   
2. Proceed and get the ResMed AirSense 10 AutoSet, or the AutoSet for Her variant as it has an additional mode. Let us know how you intend to purchase and we will guide you.
   
3. Ensure that you have an SD card any brand, 2-32GB, not bigger (4GB is a great size), this is where your machine will store detailed data
   
4. Set your range to 7-12 cmw, EPR = 2 fulltime.
   
5. Get OSCAR this will provide detailed data on which to base changes to your setup.
   
6. Post your Nightly OSCAR charts for review in THIS thread after your FIRST NIGHT.  Your settings will need to change, this is normal.
   
7. Revise as suggested, Voice your issues, etc.
   
8. Get a recording oximeter that is compatible with OSCAR, Your Oxygen levels are low enough that I would want to validate that the CPAP/AutoSet corrected your pre-CPAP low O2 levels.
   

Edit
Just read that you are Asthmatic.  I would as the doc to Prescribe the ResMed AirCurve 10 VAuto to support both your OSA and your Asthma.
For the Vauto
Mode=Vauto
Min EPAP =4
Max IPAP =15
PS =4

I'll see what my PCP can do with the AirCurve, otherwise it sounds like I need to start with ResMed AirSense 10 Autoset and show later if it's not effective to show need for AirCurve? 

I'd like to purchase through my insurance if possible, but I don't want to sacrifice quality and just pay without going through insurance, if that's what I'll need to do. I'm HDHP with a HSA and about $1k short of deductible. I would have loved to purchase outright (to be over deductible and get some things like an MRI cheaper out of pocket), but after talking to my insurance company it sounds like it's two rental periods before an outright purchase after 10 months. They gave me the names of three national vendors, Apria Healthcare, HomeLink,  and American Home Patient. There may be others approved as well, but I was given those to start and can check on others. Apria does have a local branch. 

I'll follow the rest of advice (sd card, OSCAR, etc). I'll look for info on oximeters and masks in other threads first.

[staceyburke]

I bought a “slightly used” aircurve from Supplier #2 from the supplier list at the top of this site. Only 1 month use and you can check the hours to see how many total hours it has run. Cost 799 and came with new air hoses, power, humidifier and travel case plus a year warranty great machine and company. That is less than your deductible. Only thing you need is a mask.