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Time for a new sleep study?
#1
Hi, I am writing on behalf of my dear husband who is 56 yrs old.

He has been a faithful user of CPAP for almost 10 yrs now. Pressures are 14/19 on an auto cpap machine made by RESmart. I bought it brand new from someone selling it locally about 2 yrs ago as his Respironics machine was intermittently cutting off. It came with the provider instructions and I set it up (like I've done in the past) after VERY careful research to be sure I was doing it correctly.

For the last 3-4 months he has been waking up at about 6am totally exhausted, headaches, dizziness (feels like he's falling to the left), brain fog (feels like cobwebs in his head and he just can't clear them) and he sometimes forgets things. He then has to take a 2-3 hour nap about 2-3 hours after he wakes up.

He went to the Dr, had a brain MRI 2 wks ago (came back normal) and found he has an abnormal EKG (3rd time since 2009). His primary dr thought he had a recent heart attack.

So we went to a different cardiologist at Duke this past week. He told us there is absolutely NOTHING wrong with his heart! Two yrs ago in 2014 he had a stress test, holter monitor and cardiac catheterization and everything came out fine! At that time they wanted to do MORE tests and I said NO! Enough is enough. He went thru the same thing back in 2009 (except for the cardiac catheterization) and they found nothing! The Duke Dr. advised my husband to keep the EKG with him especially if we travel out of state and he has to go to a hospital because if he has to get another EKG they will "misdiagnose" him again. The abnormality on my husband's EKG is just "normal" for him.

So my next thought (and so was the Duke Dr's) was to get an updated sleep study.

But I just looked at his sleep machine this morning to be sure the pressures were still correct... and they are. I also found an SD card in the back that I did not remember. So I downloaded the iCodes and input his info on BMC's iCode website and generated the following report below.

Day Count 182 90 60 30 7
Days of Therapy % 98% 97% 95% 90% 86%
Avg Daily Compliance 7:18 7:24 7:30 7:30 7:18
Avg P95 (cmH20) 19 19 19 19 19
Avg AHI 2 2 2 2 3

Do you think things look ok, except for the last week? I thought an average AHI of 2-3 was acceptable. I don't know why his numbers are decreasing if he uses his machine every night. Would the daily naps be throwing the numbers off a little?

So I'm wondering... does he really need another sleep study or not? I think it's probably a good idea because it's probably been about 6 yrs since he had once last. So I guess we need to just do it to double-check and rule out one more thing.

Sorry for the long post... any suggestions would be GREAT appreciated!



Attached Files
.pdf   David Doss 2.7.16 iCode Cpap Report.pdf (Size: 135.27 KB / Downloads: 56)
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#2
If you husband has had a complete medical workup and heart looks ok, then it probably wouldn't be a bad idea to get another sleep study done.
Although his AHI is fairly good, his pressure requirement is on the high side at 19cm, so it's possible he isn't getting optimal treatment. Touch base with his sleep doctor because he may need a bilevel machine where pressures can go a little higher, but you won't know without a sleep study.

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#3
What his data is telling us is that his apnea is pretty well treated at a pressure of 19 cm, but for heaven's sake, that is really high pressure, yet he apparently needs it. I would seriously push for bilevel (BiPAP / VPAP) to make his therapy more comfortable and perhaps effective. Notice you are using an auto CPAP but it is in fixed pressure mode, not the 14-19 you stated in your post. This could be a setup error and you could try using a pressure range (i.e. 14-19) and see if that is more comfortable.

I don't know what your insurance situation is, so let's talk about a couple ideas. Your husband probably does not need a sleep study. We can rely on the sensors on these machines to detect apnea. That said, you are using a Chinese manufactured auto CPAP that is not the most highly regarded machine around for data. We know the AHI is 2-3/hour, but we don't know what kind of apnea those are. His AHI may be fine, but perhaps he is experiencing respiratory event related arousals (RERA) that are disturbing his sleep, or he may not be tolerating the high pressure that is apparently needed to resolve his obstructive apnea. The data capability of the RESmart is very limited, so we don't know. Given his high pressure, he would be so much better off with bilevel therapy, such as either a Philips Respironics BiPAP Auto or Resmed Aircurve 10 VAuto. Both are bilevel machines with complete efficacy data. What a bilevel will do is give him a lower exhalation pressure to make breathing easier while supporting his airway, then increase pressure during his inhale to resolve hypopnea and RERA. I don't require those high pressures, but I'm delighted with how comfortable bilevel is.

Your family physician could prescribe bilevel based on just the symptoms you described here, without testing. That saves money, and avoids an expensive, uncomfortable night at a sleep clinic. The basis for bilevel to be approved by insurance is "that the patient has a medical necessity for positive air pressure therapy, but does not tolerate the high pressures required to resolve his condition".

That should get you the prescription and insurance justification. If you deductibles are high, then you may still wish to purchase online, or use Supplier #2 (Secondwind), who specializes in discounted used and open-box machines.

Good luck and ask any questions you have. I threw a lot at you.
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