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Titration Issues
#1
Titration Issues
Hi all!
     Confused and dismayed...lol. So I have been on CPAP (Dreamstation) for about 1.5 years now. Like most, I'm sure, have tried several masks variants and pressures settings to achieve optimal results. Initially, was tirated on a full face mask for a pressure of 13, after a sleep study (in-lab). Eventually switched to nasal prongs with Respironics due to the mask being uncomfortable.  Have been utilizing the mask now for about 8 months, and has been working well.  My pressure was set to around 8.5 H20, with a Flex of 2. However, over the past months (mentioned in an earlier post) my AHI scores have been steadily increasing and I've noticed a rise, especially, in the CA's.  So, due to concern, I repeated a lab sleep study utilizing the same mask (nasal).  They titrated me at 7 (flex unknown, if any).  So I went home and placed the machine on 7, with a flex of 2. My AHI's again were higher than normal (4-6) when I had previously been in the 1-2's. This time I noticed my Hypoapneas were now like my CA's previously...high.  So at 7, high Hypoapneas, and 8.5-9, high CA's.  I've tried Flex, no flex, changing humidity, but I can't seem to get back in the 1-2 range where I was previously.  Not sure how they got me titrated at 7 at the lab but at home it doesn't work well at all.  So, to close, my best numbers came at 8.5 with flex, but the CA's were still high.  Can someone enlighten me or help?? I truly appreciate your help.

P.S.  Wasn't able to load a snap shot of results from machine previously due to SD card, but may be able to now.  Although, since this is so erratic, was hoping someone had a good answer without needing that.
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#2
RE: Titration Issues
It would be interesting to see a copy of the titration study. We often see a titration performed where the "best titrated pressure" is either not effective, or linear with other settings attempted. This is particularly true with CA events, which are consistently inconsistent (unpredictable and not treated with CPAP pressure). There are a number of approaches to treating CA events. Again, the charts help us to visualize the type of airway instability that is present and what approach may work best. The two main techniques we go to are, the use of an adaptive servo ventilator, which is a special type of bilevel positive air pressure that resolves obstructive apnea with a stabilizing expiratory pressure, and uses pressure support to maintain the breathing volume and rate, directly treating CA by causing a breath. Another less expensive techniqe is Enhanced Expiratory Rebreathing Space (EERS) which simply moves the exhalation vent from the mask, to a point 12 to 18 inches away, and using the volume between the vent and mask to allow for rebreathing a small amount of expired CO2. This stimulates the respiratory drive and often resolves CA. http://www.apneaboard.com/wiki/index.php...ace_(EERS)

We need to back up a bit and understand the problem better. Posting your redacted titration study results and perhaps some OSCAR results will help us to better understand what is going on and even what machine you are specifically using. Instructions for organizing and attaching charts are linked in my signature.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

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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.
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#3
RE: Titration Issues
Thanks Sleeprider. I have attached the last nights readings.  I will attach redacted notes from last Sleep Study as well tomorrow at work. Unfortunately, Oscar and notes are two different locationsSad Thanks for your help.  Let me know if you need anything else.


Attached Files Thumbnail(s)
   
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#4
RE: Titration Issues
This last one looks more obstructive. It might be interesting to get some closeups of the flow rate (2-3 minutes) to see what is going on around some of the hypopnea.
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.
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#5
RE: Titration Issues
I can get whatever portion you need, just let me know.  Interesting enough, I reviewed past AHI's and pressures on the stat sheet. In 2019, for one week, my AHI's were in the tenths, so I changed my settings last evening (9cm H2O with Flex 2) just to see how that would do.  I ended up with an AHI of 2.5, 10CA, 0 OA, and 3 HA.  I can post later if you like. Now at the time, I believe this was on the Full Face mask by Respironics (not sure the name, but goes under the nose and over the mouth). So don't know if I can compare the pressures, since one was a full, and now I have nasal prongs.  Either way, the pressure seemed to help my numbers. Additionally, I think it actually felt better overall last evening, except when I awoke in the middle of the night, I should have ramped back up, because it was difficult getting back to sleep with that pressure.  As far as the sleep study reports, do you want to see the initial PSG or the Titration report?

Thanks again! Thanks
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#6
RE: Titration Issues
Redacted copies of both sleep studies please, and don't forget the closeup, 2 to 3 minute view of some hypopnea events.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

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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.
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#7
RE: Titration Issues
Thanks for your help! I have attached the latest titration study, as was as the initial PSG determining my level of OSA.  I will post the requested 2-3 minute look tobight once home.  Thanks again. Thanks

More to the testing.

And lastlySmile


Attached Files
.pdf   Scan2020-09-02-033611.pdf (Size: 690.96 KB / Downloads: 10)
.pdf   Scan2020-09-02-033628.pdf (Size: 915.97 KB / Downloads: 9)
.pdf   Scan2020-09-02-033704.pdf (Size: 603.19 KB / Downloads: 5)
.pdf   Scan2020-09-02-033720.pdf (Size: 733.97 KB / Downloads: 7)
.pdf   Scan2020-09-02-033736.pdf (Size: 407.69 KB / Downloads: 4)
.pdf   Scan2020-09-02-033751.pdf (Size: 400.57 KB / Downloads: 4)
.pdf   Scan2020-09-02-033808.pdf (Size: 395.01 KB / Downloads: 5)
.pdf   Scan2020-09-02-033825.pdf (Size: 362.23 KB / Downloads: 4)
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#8
RE: Titration Issues
I would ask for a full copy of the Sleep report, including the table and charts. This is just the summary which often leaves out important details.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Soft Cervical Collar
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

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.
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#9
RE: Titration Issues
For me personally, my titration sleep study was a one-off. It reflected one mere night using their mask and machine, in their bed & room, with wires hooked up all over me, knowing I was being video-monitored, and me having to ask permission to use the restroom. I also only "slept" (if you can call it that) for about 4 hours. None of that represented how I typically slept at home.

In my titration report, the dr recommended a pressure of 5 because they started at 4, then 5 where I had the fewest apneas, then 6 where I had very slightly more than at the pressure of 5, and then 7 where I also had slightly more than at the pressure of 5. They never made it to a higher pressure because I didn't sleep long enough. And because I had slightly fewer apneas at the pressure of 5, then that must forever more be my pressure.

After 3 weeks on CPAP, I complained to my sleep "doctor" about air hunger, and asked about raising the pressure or at least getting an APAP (he had Rxed - and I had received - a fixed pressure CPAP). He said no, because my titration showed the fewest apneas at 5, and because my CPAP SD card showed that my AHI was lower than my sleep study AHI (and lower than 5).

So... in my opinion, the titration sleep study is just a snapshot of one lousy night of irregular sleep. And it would be best to look at your consistency of sleep on CPAP over time.
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#10
RE: Titration Issues
I will certainly ask.  As published, the graphics were available with the initial, but I only received the "summary" for the titration.  Let me call and see what they can provide.

I totally agree with the "lack of a goodnight" and snap shot theory.  I found the pressure they agreed upon initially was way to much, and then the second time I tirated, it was way to little. I've has to "self" experiment to try and find a happy solution, thus, here I am! lol   Hopefully, with all of your help, I can finally find that magic zone that will give me a decent nights sleep...not even holding out for great!
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