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Titration Study - Poor Results?
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MeDee Offline

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Posts: 21
Joined: Jan 2016

Machine: ResMed AirCurve Vauto
Mask Type: Nasal mask
Mask Make & Model: Swift FX Nano
Humidifier: Yes
CPAP Pressure: IPAP: 4, EPAP: 10 (PS 4)
CPAP Software: SleepyHead

Other Comments:

Sex: Undisclosed
Location: USA (Thermian)

Post: #1
Titration Study - Poor Results?
I had my titration study and a few things popped out.

1. Even with CPAP my apnea remained - possibly reduced by half but still above what I expected.
2. I will not see a doctor until I have bought the equipmet and tested it for 1 month.

I can always push for another office visit, but would love some context from people who have walked this path before. I don't know exactly what to include so please let me know if more is needed.

Also, any machine/mask suggestions?

WITHOUT CPAP

RESPIRATORY ANALYSIS: (index = #/hr)
Apnea/Hypopnea Index (AHI): 60.9
NREM AHI: 58.4
REM AHI: 83.8
Non-Supine AHI: -
Supine AHI: 60.9

Respiratory Disturbance Index (RDI): 62.2
NREM RDI: 59.9
REM RDI: 83.8

Apneas (index, #): 12.3 (66)
Obstructive Apneas (index, #): 6.2 (33)
Mixed Apneas (index, #): 1.7 (9)
Central Apneas (index, #): 4.5 (24)
Hypopneas (index, #): 48.6 (260)
RERAs (index, #): 1.3 (7)

Mean Awake SpO2: 95%
Mean Sleep SpO2: 94%
Minimum Sleep SpO2: 85%
Sleep Time with SpO2 < 88% (min, % of TST): 1.7 (0.5%)



WITH CPAP - we tested 2 full face and one nasal mask

RESPIRATORY ANALYSIS: (index = #/hr)
Apnea/Hypopnea Index (AHI): 30.0
*AHI 4% or greater: 14.3
NREM AHI: 28.8
REM AHI: 54.5
Non-Supine AHI: 0.0
Supine AHI: 30.0

Respiratory Disturbance Index (RDI): 31.4
NREM RDI: 30.2
REM RDI: 54.5

Apneas (index, #): 11.2 (64)
Obstructive Apneas (index, #): 5.2 (30)
Mixed Apneas (index, #): 0.0 (0)
Central Apneas (index, #): 5.9 (34)
Hypopneas (index, #): 18.8 (108)
RERAs (index, #): 1.4 (8)

Mean Awake SpO2: 96%
Mean Sleep SpO2: 93%
Minimum Sleep SpO2: 86%
Sleep Time with SpO2 < 88% (min, % of TST): 0.4 (0.1%)
CLINICAL INTERPRETATION:

1. Obstructive Sleep Apnea, demonstrated previously.

2. The obstructive sleep apnea was best treated with Bilevel at
15/11 cm H2O which was tested in supine but not REM sleep. The
SpO2 nadir on this pressure was 93%. Respiratory events
persisted with all tested CPAP settings.

3. Central apneas, mainly occuring during periods of
transitional sleep


RECOMMENDATIONS:

1. Regular use of Bilevel PAP at 15/11 cm of water should
effectively treat the patient's sleep apnea. If breakthrough
respiratory events are noted on this pressure then Auto Bilevel
with min EPAP of 11, Max IPAP of 20 and PS of 4 cm of water
should be considered. Best results were achieved with a small
F&P Eson mask. Respiratory events appeared to be more frequent
when a full face mask was used. A heated humidifier was used
during the titration.
02-23-2016 01:38 PM
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Dawei Offline

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Posts: 342
Joined: Feb 2012

Machine: ResMed S9 AutoSet
Mask Type: Other
Mask Make & Model: Respironics "FitLife"
Humidifier: H5i
CPAP Pressure: 10-20
CPAP Software: ResScan SleepyHead

Other Comments: Began CPAP in 2006; spent the first 6 years with a "brick"

Sex: Male
Location: Western North Carolina

Post: #2
RE: Titration Study - Poor Results?
I'm trying to understand why you plan to buy equipment and test it before seeing a doc? Sounds like your equipment decisions are to based on board members' opinions without any input from a sleep doc. Following this path, why plan to see a sleep doc at all? What will he/she be able to offer you if you've gone ahead without letting one see your titration results?

David
02-23-2016 09:59 PM
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Dawei Offline

Preferred Members-2

Posts: 342
Joined: Feb 2012

Machine: ResMed S9 AutoSet
Mask Type: Other
Mask Make & Model: Respironics "FitLife"
Humidifier: H5i
CPAP Pressure: 10-20
CPAP Software: ResScan SleepyHead

Other Comments: Began CPAP in 2006; spent the first 6 years with a "brick"

Sex: Male
Location: Western North Carolina

Post: #3
RE: Titration Study - Poor Results?
P.S. One reason for my response is that it appears to me (and I'm not a doc) that your sleep study shows a somewhat complex situation. My understanding is that the therapy goal is to get AHI down to at least 5 if not below that number. Your CPAP results, as you mentioned, didn't appear to reach that desired AHI level. I also wonder how significant the Centrals are in your titration. Both of these factors may lead a sleep medicine doc toward a machine other than straight xPAP, such as a bi-level, auto bi-level or even ASV machine to meet your needs and truly control your AHI. I don't know the answer, and my view is that other board members are also not in a position to positively identify your situation, since theirs may be similar, but close is often not good enough, as it is with horseshoes and hand grenades.

David
02-23-2016 10:15 PM
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MeDee Offline

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Posts: 21
Joined: Jan 2016

Machine: ResMed AirCurve Vauto
Mask Type: Nasal mask
Mask Make & Model: Swift FX Nano
Humidifier: Yes
CPAP Pressure: IPAP: 4, EPAP: 10 (PS 4)
CPAP Software: SleepyHead

Other Comments:

Sex: Undisclosed
Location: USA (Thermian)

Post: #4
RE: Titration Study - Poor Results?
(02-23-2016 09:59 PM)Dawei Wrote:  I'm trying to understand why you plan to buy equipment and test it before seeing a doc? Sounds like your equipment decisions are to based on board members' opinions without any input from a sleep doc. Following this path, why plan to see a sleep doc at all? What will he/she be able to offer you if you've gone ahead without letting one see your titration results?

David

The doc has sent his equipment recommendations to the DME (which he did not disclose to me) but will not see me before I buy unless I find a good enough reason to push back. This is an HMO situation where I do need to have some reason to ask for an in person appt. I had hoped this would be a simple: "it is totally OK if your titration study still left you in severe apnea, this often happens" or "hhhm, this might be a good time to ask for more a deeper look."

Asking for equipment recommendations seems a no brainer - as in"hey I love my nasal mask X". So when I meet with the DME I can ask for several models based on the docs parameters instead of being shoved into whatever is on hand.
02-23-2016 10:29 PM
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MeDee Offline

Preferred Members

Posts: 21
Joined: Jan 2016

Machine: ResMed AirCurve Vauto
Mask Type: Nasal mask
Mask Make & Model: Swift FX Nano
Humidifier: Yes
CPAP Pressure: IPAP: 4, EPAP: 10 (PS 4)
CPAP Software: SleepyHead

Other Comments:

Sex: Undisclosed
Location: USA (Thermian)

Post: #5
RE: Titration Study - Poor Results?
(02-23-2016 10:15 PM)Dawei Wrote:  P.S. One reason for my response is that it appears to me (and I'm not a doc) that your sleep study shows a somewhat complex situation. My understanding is that the therapy goal is to get AHI down to at least 5 if not below that number. Your CPAP results, as you mentioned, didn't appear to reach that desired AHI level. I also wonder how significant the Centrals are in your titration. Both of these factors may lead a sleep medicine doc toward a machine other than straight xPAP, such as a bi-level, auto bi-level or even ASV machine to meet your needs and truly control your AHI. I don't know the answer, and my view is that other board members are also not in a position to positively identify your situation, since theirs may be similar, but close is often not good enough, as it is with horseshoes and hand grenades.

David

Thank you for the clarification. The last email I had from my doctor before the titration study was that the centrals were not important because they happened in a ...transitional state? And that my case was "not complex" which is why I was confused when the AHI numbers remained above 30 even with CPAP. I think they tried a straight CPAP first on me, then flipped the switch to biPAP (again the sleep tech would not answer any questions about what machines or masks we were using). he didn't even want to try the last mask (nasal one) because we were close to the end of the study but I managed to talk him into letting me at least wear it for fit. I did not have enough time to fall into REM but I did fall asleep with it on and it didn't hurt my jaw like the 2 full face masks.

So I am basically trying to get a baseline from other people who have gone through this to set my expectations for how best to work with the DME that my doctor has told me to use.
02-23-2016 10:36 PM
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DeepBreathing Offline
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Posts: 2,294
Joined: Sep 2013

Machine: Resmed S9 VPAP Adapt
Mask Type: Full face mask
Mask Make & Model: F&P Simplus
Humidifier: Resmed H5i
CPAP Pressure: EPAP: 9 - 15 PS: 3 - 10
CPAP Software: ResScan SleepyHead

Other Comments:

Sex: Male
Location: Perth, Western Australia

Post: #6
RE: Titration Study - Poor Results?
A "treated" AHI of 30 is still severe apnea - in other words, not treated. Ignoring the central apneas, you still have a "treated" obstructive AHI of 24.1 - NOT TREATED at all. If you had a few centrals while transitioning in and out of sleep, then yes, they can be ignored. But your mixed and central apnea index > 5, meaning you need treatment for the centrals. Note also the central index got worse when you were under CPAP/Bipap.

I don't know what kind of system you're operating under, but to me this does not seem at all acceptable. Technician won't talk to you; doctor won't give an appointment; doctor has ordered a machine but won't tell you what kind; doctor is ignoring the fact that you still have severe apnea even under bipap treatment; doctor is ignoring the fact that your central apnea is probably bad enough to warrant an ASV machine. I think you're being fobbed off: I assume you have some kind of rights - I suggest you start demanding them.

DeepBreathing
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.
02-23-2016 11:52 PM
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DariaVader Offline
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Posts: 1,820
Joined: Nov 2014

Machine: Resmed S9 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: Airfit P10 for Her
Humidifier: H5i humidifier with ClimateLine heated hose
CPAP Pressure: 8-15
CPAP Software: SleepyHead

Other Comments: diabetes II, Thyroidectomized, Primary Immune Deficiency, and the list goes on :P

Sex: Female
Location: Oregon

Post: #7
RE: Titration Study - Poor Results?
It does appear that the titration study tried some settings that *didn't* work well and others that did work "acceptably"... although with a study like that I can certainly see wanting a thorough explanation before putting money out of pocket.

هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
Tongue Suck Technique for prevention of mouth breathing:
  • Place your tongue behind your front teeth on the roof of your mouth
  • let your tongue fill the space between the upper molars
  • gently suck to form a light vacuum
Practising during the day can help you to keep it at night

هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
02-24-2016 12:12 AM
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MeDee Offline

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Posts: 21
Joined: Jan 2016

Machine: ResMed AirCurve Vauto
Mask Type: Nasal mask
Mask Make & Model: Swift FX Nano
Humidifier: Yes
CPAP Pressure: IPAP: 4, EPAP: 10 (PS 4)
CPAP Software: SleepyHead

Other Comments:

Sex: Undisclosed
Location: USA (Thermian)

Post: #8
RE: Titration Study - Poor Results?
Thank for your summary. As a layperson I assumed that an untreated apnea of 30 with CPAP was "not good". Didn;t know that the mixed + centrals being > 5 = treatment needed. The increase in central from 4.5 to 5.9 seemed ...small? 30%? am terrible with numbers. Plus, they kept saying to ignore the centrals.

I did ping their office and was told that the reason my numbers were so bad was because they were trying several modes. "Obviously, your results won't be as good in the lab until we have find the right combination in the lab and you have tested it at home for a month." So yes, I am getting the picture that I am not getting thoughtful treatment. I've put in a request for the full sleep study tests (both of them) and will proceed from there. Either an in person follow-up or an out-of-pocket second opinion. I can also call the DME and ask them what he has prescribed - it may be something different than what the tech suggested in the report.
02-24-2016 12:17 AM
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Crimson Nape Offline

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Posts: 1,327
Joined: Oct 2014

Machine: ResMed S9 Autoset
Mask Type: Other
Mask Make & Model: P-10 / F&P Simplus / DreamWear
Humidifier: H5i w/Climateline
CPAP Pressure: 8 - EPR 3
CPAP Software: SleepyHead

Other Comments: CMS-50F & 50IW

Sex: Male
Location: Georgia

Post: #9
RE: Titration Study - Poor Results?
I agree with DeepBreathing.

I also have additional questions. Is the sleep doctor your primary or a Pulmonologist? Your report stated that you tried 3 different masks during your titration study; How long did you sleep totally and with each mask? One night seems to me to be too short for three masks.

You have certain rights no matter where you live but different countries can have different rights. (That isn't totally worded correctly but is the best I can do at this time) Let us know if you are in the U.S., Canada, Australia, or somewhere else. This will help in providing recommendations.

Statistics prove that people who have more birthdays live longer.
02-24-2016 12:27 AM
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MeDee Offline

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Posts: 21
Joined: Jan 2016

Machine: ResMed AirCurve Vauto
Mask Type: Nasal mask
Mask Make & Model: Swift FX Nano
Humidifier: Yes
CPAP Pressure: IPAP: 4, EPAP: 10 (PS 4)
CPAP Software: SleepyHead

Other Comments:

Sex: Undisclosed
Location: USA (Thermian)

Post: #10
RE: Titration Study - Poor Results?
(02-24-2016 12:27 AM)Crimson Nape Wrote:  I agree with DeepBreathing.

I also have additional questions. Is the sleep doctor your primary or a Pulmonologist? Your report stated that you tried 3 different masks during your titration study; How long did you sleep totally and with each mask? One night seems to me to be too short for three masks.

You have certain rights no matter where you live but different countries can have different rights. (That isn't totally worded correctly but is the best I can do at this time) Let us know if you are in the U.S., Canada, Australia, or somewhere else. This will help in providing recommendations.

We live in the US. The doctor is the sleep specialist (neurologist) not a primary MD.

Re time sleeping.....

This is all I have

SLEEP SCORING DATA:
Lights Out / On (clock times): 23:04:27 / 06:39:28
Total Recording Time (TRT) (min): 455.5
Total Sleep Time (TST) (min): 344.0
Sleep Efficiency: 75.6%
Sleep Latency (min): 5.0
Stage REM Latency (min): 216.5
Wake after sleep onset (WASO) (min): 106.0

Stage N1 Sleep (min, % of TST): 25.0 (7.3%)
Stage N2 Sleep (min, % of TST): 301.0 (87.5%)
Stage N3 Sleep (min, % of TST): 1.5 (0.4%)
Stage R Sleep (min, % of TST): 16.5 (4.8%)
Supine Sleep (min): 344.0
Arousals (index, #): 32.6 (187)

I don't know how long I slept with each mask - except the last one. That is because when I finally asked them to remove the 2nd full face mask because of the jaw pain, I looked at my watch. I slept with the last mask (Nasal) around 90 minutes but never entered REM (I think that is what the report said).

Let me know if any further info will help you folks help me navigate the next steps. I would like to have some basic questions before I try to see the doctor again.
02-24-2016 12:34 AM
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