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Titration study revisited
#1
Titration study revisited
Back story: I was diagnosed with severe sleep apnea in 2006. Untreated AHI in the sleep study was 42. I was put on simple CPAP at a constant pressure of 11, and I did that for almost 10 years before deciding I needed a new machine. During those ten years I didn't see the sleep doctor again. I didn't think there was any need to, since I was having no troubles with the CPAP, and his office never called me to schedule anything. The Resmed S8 was not data capable, so I have no idea what was going on with my AHI during those years.

When, in the fall of 2015, the S8 started to get noisy, I contacted the doctor about replacing it. He ordered a Dreamstation without doing a new sleep study. The Dreamstation, of course, is data capable, so I started looking at the data, which showed quite a lot of periodic breathing and centrals. I didn't know what any of this meant, but my AHI on this machine was often above 10, and that didn't seem like a good thing. After various delays and medical checkups, another sleep study was done, confirming the presence of central apneas, and by March 2016 I was on the Phillips System One Advanced ASV that I'm still using.

The summary table from the titration study is attached.

The resulting prescription was for PSmin=0, EPAPmin=8. As you can see from the table, this EPAP setting is correlated with the lowest AHI but not the lowest RERA or RDI, and it has the highest SAI (spontaneous arousal index). I'm vaguely aware that different doctors use different indices as a guide to prescribing. But I've been very curious about the SAI number. Spontaneous arousals are theoretically not related to apnea events, right? Hence the term "spontaneous." But if they were really spontaneous, I'd expect a more or less constant distribution of them at different settings, but that's not what we see. They are much higher at EPAP=8 than at any other setting. I suppose that could be just a fluke, but if the goal is to find the setting that provides the most undisturbed sleep, you'd think the doctor would want to investigate that. He's not terribly interested in it.

If I add the SAI to the RDI, I'd get 6.1 at EPAP=7, 15.5 at EPAP=8 (where it's currently set), and 6.0 at EPAP=9. You'd think that would matter, wouldn't you?


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#2
RE: Titration study revisited
I would suppose that AHI is at treated of 5 or less. If so, that's all Dr. Duck wants to see, all other info is not necessary and really doesn't matter to them. I had to make my doc look at what disrupted my sleep, I suggest doing the same. Better yet, if your machine can address it, adjust it accordingly. Don't wait on Dr. Dopey Duck. Maybe he should be terminated and replaced with one that actually listens to patients concerns.
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.
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#3
RE: Titration study revisited
(11-14-2019, 12:12 PM)SarcasticDave94 Wrote: I would suppose that AHI is at treated of 5 or less. If so, that's all Dr. Duck wants to see, all other info is not necessary and really doesn't matter to them. I had to make my doc look at what disrupted my sleep, I suggest doing the same. Better yet, if your machine can address it, adjust it accordingly. Don't wait on Dr. Dopey Duck. Maybe he should be terminated and replaced with one that actually listens to patients concerns.

Actually, I did replace my old sleep doc, who was a pulmonologist, with a new one, who's a neurologist. But the new one is actually the one who conducted the sleep study, wrote the report, and made the prescription recommendations. He runs the sleep lab. He's okay, in the sense that he has no objection to my various experiments with settings, etc. But he tends to be "by the book," and since there's no standard treatment protocol for SAs, he just doesn't pay much attention to them.

I don't plan on touching settings for a little while, since I'm still adapting to a new mask, but at some point I'll try EPAP at 7 or 9. I have no way to monitor SAs but I can at least see how I feel. I did some of this when I first got the ASV machine, but back then I was still trying to adjust to the whole ASV experience, so I don't think I really learned much.
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#4
RE: Titration study revisited
Could you be arousing due to sounds, and not due to any other occasional events?  Or, do you sometimes experience pains when arousing, say on an ear that has been compressed when you sleep on your side?  This is surprisingly common.  Periodic leg movements are spontaneous, but they will arouse you. Noises will arouse you.  Flatus will arouse you.  An active mind will arouse you.  So will post nasal drip. 

I use silicone plugs in my ears at night.  They come in a clear plastic package of four, and are shaped like tall cookies.  I have small ear canals, so I can pinch one of them in half, roll each to suit, and then mash it into my ear.  They work better than the foam ones IMO.  Might be worth a try to see if sounds are what are bothering you.
Serial Tapist
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#5
RE: Titration study revisited
Copy on that.
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.
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#6
RE: Titration study revisited
Well, the only evidence I have for the SAs is the sleep study itself, which was done in the lab, a very quiet setting. If they were caused by sounds, it's puzzling that they would have clustered at the EPAP=8 setting. As I understand it, SA events are measured by EEG as interruptions of Delta sleep.

Beats me.
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#7
RE: Titration study revisited
Can you get the full titration report?

All you have is a summary and there is no way to know anything from that other than for 135min of your life you had the highest spontaneous arousals. I'm not sure how much detail you can get just from even the full report. Ideally you would want to be able to match up what was going on when you had these events.

Since you can't measure EEG Arousal on a daily basis, all this information would do is give you some idea what happened during the study. It is just one night in a lab with wires hooked up all over you. What are you going to do?

FWIW... For 10 years I merrily went along with a ResMed S6. After I got an S9, I started looking at data (AHI always over 5 and 60% centrals) and with information I got from online forums I was able to make improvement tweaks for a while.

Recently I got an ASV machine. I hadn't seen a sleep doctor for over 15 years. I check my numbers daily, but I sleep better and my AHI is under 1. I have a few questions for my sleep doctor, (one is my RR is 10), but overall things are going really good. I will always look at my data, but there is a part of me that was happier when I was on my S6 and I wasn't looking for rabbit holes.

John
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#8
RE: Titration study revisited
(11-14-2019, 03:34 PM)70sSanO Wrote: FWIW... For 10 years I merrily went along with a ResMed S6.  After I got an S9, I started looking at data (AHI always over 5 and 60% centrals) and with information I got from online forums I was able to make improvement tweaks for a while.

Recently I got an ASV machine.  I hadn't seen a sleep doctor for over 15 years.  I check my numbers daily, but I sleep better and my AHI is under 1.  I have a few questions for my sleep doctor, (one is my RR is 10), but overall things are going really good.  I will always look at my data, but there is a part of me that was happier when I was on my S6 and I wasn't looking for rabbit holes.

John
Boy I know exactly what you mean. For ten years I just put my mask on and went to sleep, woke up and took it off. I had no clue about my AHI and could care less. I looked at CPAP as something like wearing glasses. Once you wear them you always need them and you just do it. I felt fine and was utterly uninterested in things like RERAs and pressure support.

My constant CPAP pressure of 11 never bothered me. In contrast, the ASV's more aggressive approach sometimes bothers me. I have no idea if, on balance, I'm really better off with it.

I do have the full titration report, but it's not very edifying. It also mentions a significant number of PLMs. My wife insists this isn't an issue.
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#9
RE: Titration study revisited
You might want to look into the PLMs as that might be an underlying cause of some of your sleep disruption. It probably won’t show in any if your sleep data, but if you feel it is impacting your sleep, it might be worth it. At least it is something that can be addressed “by the book” more than the SA’s.

I know someone with restless leg and it really impacted her, but that is more severe.

John
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