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Your thoughts on study and titration estimates
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Muchosueno Offline

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Post: #1
Your thoughts on study and titration estimates
Hello,
My child has been through an initial sleep study, T&A, and follow up sleep study.
Now we are going in for another appt after my daughter has been acclimating to the cpcp/mask for the last month.
One of her major issues is she doenst expel CO2, shallow breather.

I dont have a whole lot of faith in the sleep lab at a major childrens hospital here incentral TX
During our last appt after the dr left the room I had additional questions and he wouldnt come out of the lounge next door to answer.
He had the nurse take my questions down on a piece of paper and told her the answers to give to us.

Needless to say I really need your input on what a titration estimates. The doc says he will deciede after tommorrows appt if he will do a titration study.
I thought it was part of the neccesary process???
Any way here is the latest sleep study results if you can check them out and let me know your thoughts....thank you!

Hello all,
I have been reading, reading, reading, trying to learn all about the intricacies of sleep apnea.
I have a delightful(when rested) 4 year old girl who has Trisomy 21-Down Syndrome.
She is doing quite well health wise and cognitively. No heart problems. No iron deficiencies.
I have noticed since she was about a little over one year old that she would seem fatigued and tired even upon awakening.
I have been voicing my concerns to doctors with only the comment of "That is part of the diagnoses"
Bull !@#!! Us parents know our kids best.
She finally had a sleep study last summer and her tonsils and adenoids out on the first of this year.
I have had a FOLLOW UP sleep study after the surgery and have the results I need help with.
I am going to see the Pulmonolgist at the sleep lab this Friday so he can decide if he wants to do a titration study and I want to be fully informed as to why, offer my suggestions and observations.

If you can help me out I'd appreciate it!!!



Scoring was perfored using the following derivations
(International 10-20 system) for electophysiocgic sleep parameters: F4-M1, C4-M1, o2-M1, F3-M2, c3-M2, o1-M2 with submentla electromyogram (EMG) and electroocuculogram (EOG) in E1-M2 derivations. Cardiac rhythm was monitored continuously with a pair of chest electrodes in Lead II placement. Periodic limb movements were monitored by anterior tibialis EMG (Recommended by ASM for two recording channels (left and right). Assessment of airflow was made by oronasal thermistor and nasal pressure transducer. Hypoventilation was assessed by end-tidal PCO2 monitoring. Arterial pulse oximetry (SpO2) was measured with an internal oximeter. Respiratory effort was monitored using intercostal EMG and inductance plethysmography belts over the dchest and abdomen. In addition to the standard digital channels, synchronized videography and audiography were obtained a s standard protocol. Data was collected utilizing SomnoStar polysomnography soft wear. Observations of abnormal behavior, snoring intensity and body position were documented and time-stamped as polysomnographic events.

ELECTROPHYSIOLOGIC MEASUREMENTS:
Sleep architecture is fragmented during the study. The patient had 5 distinct areas of REM. REM supine sleep was present.
The patient spent a total of 8.9 hours in bed with a total sleep time of 7.4 hours, resulting in a sleep efficiency of 83.3% (normal greater than 90%)
LAtnecy to sleep onset was 8.5 minutes.
Arousal index was 7.2 per hour.
Respiratory associated arousals were 1.1/hr.
PLMS associated arousals were 0.5/hr.
Sleep stages are as follows: 13.5 minutes in N1 (3% of TST), 214.5 minutes in N2 (48.4% TST), 114 minutes in N3 (25.7% of TST), 101.5 minutes in REM (22.9 of TST).
Latency to REM onset was 66.5 minutes.
The patient had a total of 52 periodic limb movements in sleep, resulting in aPLMS index of 7/hr.


RESPIRATORY MEASUREMENTS:
The study was performed on room air. Mean Spo2 during sleep was 95%.
Spo2 nadir of 87% was present.
Desaturation index was 7.8/hr.
Desaturation index in REM was 10.6/hr.
The patient spent 100% of TST with ETCO2 greater than 50 mmHg.
The patient spent a total of 99.7% of TST with SpO2 greater than 89%.
The patient had a total of 0 central apneas and 31 hypoapneas, resulting in an apnea/hypoapnea index (AHI) of 4.2/hr.
The patient's AHI in REM was 5.9/hr.
The patient's AHI in supine sleep was 4.5/hr.
Two of the hypo apneas were associated with awakenings. Longest duration of a hypoapnea was 15 seconds.
SpO2 nadir of 89% was associated with a hypo apnea.
Obstructive apnea and hypo apnea index (OAHI) was 4.2/hr.
Airflow limitation was present on the study. Snoring was intermittently present. Mean respiratory rate during sleep was 18-20 breaths per minute.


ELECTROCARDIAOGRAPHIC OBSERVATIONS:
Single lead EKG demonstrates an average sleeping heart rate of 98 beats per minute.

CLINICAL OBSERVATIONS;
Sleep was otherwise grossly normal. There is mouth breathing observed in this study. The patients parent felt that the sleep quality was much worse than usual.

CONCLUSIONS:
Sleep study demonstrates mild pediatric obstructive sleep apnea (AHI 4.2/hr, OAHI 4.2/hr) with mild increase in frequency of respiratory events in REM (AHI 5.9/hr). Two of the hypoapneas were associated with awakenings. Oxygenation instability is present. Nocturnal hypoventilation was not present. Airflow limitation was present. Snoring was intermittently present.
Mild periodic limb movements in sleep is present (PLMS index 7/hr). Periodic limb movements in sleep can be seen in the setting of sleep disordered breathing. Periodic limb movements in sleep can also be seen in the setting of low levels of iron, including ferritin (less the 50 ng/mL in suseptible individuals.
GTF2S

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10-11-2012 05:17 PM
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PaulaO2 Offline
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Post: #2
RE: Your thoughts on study and titration estimates
Well, not sure how much I can help.

With an AHI of that low, she is about average. The diagnoses doesn't even start until the AHI reaches 5. I don't think sleep apnea is the cause for her sleep issues. No central events which is good. And she slept a long time which is also good. That means the data is justified. The numbers might be different for children, however. The AHI (apnea hypopnea index) is the number of apneas (stopped breathing) added to the number of hypopneas (shallow breathing) divided by the number of hours slept.

Periodic Limb Movement Syndrome/Disorder is where her legs (although it could be other body parts) jerk, bringing her out of deep sleep. It may not be waking her up all the way, however. With obstructive sleep apnea, the jerking is our brains trying to wake us up and breathe. The muscles in our throat that help with swallowing and talking, are voluntary muscles. So when we relax in sleep, so do they. We have to come out of sleep enough to tighten them up again. The end of the report mentions PLMS but I'm not sure if they are just stating what it is or saying this is what happened in her sleep.

If this were me, I'd be concerned about the low oxygen at night. That alone could be making her tired. Perhaps instead of a CPAP, she could be using supplemental oxygen at night.

But then, I'm not a doctor. Just hypothesizing.

PaulaO2
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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.
10-11-2012 06:15 PM
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Dawei Offline

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Post: #3
RE: Your thoughts on study and titration estimates
I see that your daughter has already had two sleep studies and has been using a CPAP machine. So, I, too, wonder what the doc has in mind in thinking about a titration study, which I assume would mean a third night in the sleep lab. The usual, in my experience, was first an oximeter for one night which I took home to record oxygen levels during the night. That was followed by a two-part sleep study carried out on two different nights. The first night is to determine if apnea is present at a level for which treatment is called for. If so, the second night (part two) is set up for the purpose of finding the proper pressure for the CPAP machine (titration). I have also read reports of some folks going in for their first sleep study and during that night with a high level of apneas (AHI) present, the lab tech has gone ahead and done the titration that same night.
As Paula mentioned, the CPAP goal is to get the AHI below 5, but you might want to find out if that same number is also the goal for a young child.
10-11-2012 06:45 PM
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trish6hundred Offline

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Post: #4
RE: Your thoughts on study and titration estimates
Hi Muchosueno, WELCOME! to the forum.!
It's good that you are taking such an interest in your child's care.
.
Hang in there for more suggestions and best of luck to you.

trish6hundred
10-11-2012 07:12 PM
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zonk Offline

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Post: #5
RE: Your thoughts on study and titration estimates
read somewhere for children AHI between below 5 considered mild sleep apnea and greater than 5 moderate sleep apnea
how the AHI now since been using the machine and how she is coping with the mask
10-11-2012 07:55 PM
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Muchosueno Offline

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Post: #6
RE: Your thoughts on study and titration estimates
Thank you all for your interest in my concerns.
From what I understand for pedi they try to get it under a AHI of 2, anything over that would be mild sleep apnea.
And yes, a major concern is that 100% of the time while asleep she is only expiring 50% of CO2.

They sent her home with the Respironics Profile lite nasal gel mask.
Then 2 weeks later her mask was changed to the Fitlife full face mask.
She has been wearing both over 7 hours per night.
According to her machine set at 4cm -Resmed Elite S9 her AHI was down to 1- 1.5 per hour
But she is still sooo tired and my fear is she is rebreathing the CO2 in the FITLife mask.
How can they measure this?
Can they compensate this with a higher CM setting?
What is the EPR setting? does this apply to her?

In any of your expirience would a CPAP machine be able to correct the co2 non expiration problem?
Ive read that it is harder to exhale with the force of the air.

Thank you again for your input.
10-11-2012 09:05 PM
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PaulaO2 Offline
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Post: #7
RE: Your thoughts on study and titration estimates
Found some stuff:

Quote:Hypopneas are episodes of shallow breathing during which airflow is decreased by at least 50%. They are usually accompanied by some degree of oxygen desaturation, which can be minor and transient. Like apnea, hypopnea is subdivided into obstructive, central, and mixed. Obstructive hypopneas are episodes of partial upper airway obstruction. Respiratory efforts occur, but airflow is reduced. In central hypopnea, breathing effort and airflow are both decreased. Mixed hypopneas have both central and obstructive components.

In adults, episodes of disordered breathing must last 10 seconds or more before being considered an apnea or hypopnea. Normal resting respiratory rates in children are faster than those in adults, and children have a smaller functional residual capacity and a more compliant chest wall. As a result, children undergo oxygen desaturation more rapidly than adults whenever airflow is interrupted. A definition of apnea or hypopnea requiring that an event last 10 seconds or more before being considered significant is somewhat arbitrary and does not take into account the physiologic differences between adults and children. Consequently, pediatric sleep centers use different duration criteria for labeling events such as apnea or hypopnea. In children, if obstruction occurs with 2 or more consecutive breaths, the event can be called an apnea or hypopnea, even if it lasts less than 10 seconds.

(...)

Childhood sleep apnea differs from adult obstructive sleep apnea in that adults with sleep apnea frequently present with hypersomnia, whereas children often demonstrate short attention spans, emotional lability, and behavioral problems. Obesity is a major risk factor in both adults and children.[1] Fatty infiltration of the pharyngeal soft tissues narrows the caliber of the upper airway and contributes to airway resistance. Although obesity plays a role in some cases of childhood sleep apnea, the airway obstruction is usually related to tonsillar hypertrophy, adenoid hypertrophy, or craniofacial abnormalities. Children with some types of neuromuscular disease (eg, Duchenne muscular dystrophy, spinal muscular atrophy, cerebral palsy) may also have a higher risk of developing sleep apnea.

(...)

Obesity and hypertrophy of tonsils and/or adenoids account for most cases of obstructive sleep apnea in children.[1] However, any anomaly of the upper airway may produce intermittent obstructive symptoms during sleep. Facial, oral, and throat eccentricities occur in numerous congenital syndromes. Certain storage diseases, hypothyroidism, and Down syndrome result in upper airway crowding due to a relative increase in tongue mass compared to mouth size.

(...)

The major determinants of surgical outcome include the apnea hypopnea index (AHI) and obesity at the time of diagnosis. The AHI is the total number of apneas and hypopneas that occur divided by the total duration of sleep in hours. An AHI of 1 or less is considered to be normal by pediatric standards. An AHI of 1-5 is very mildly increased, 5-10 is mildly increased, 10-20 is moderately increased, and greater than 20 is severely abnormal.

(the above bit was referring to surgical options for childhood apnea and the AHI expected after the surgery. it was confusing.)

The same article had this:
[Image: 1331341-1331361-1004104-1953341.jpg]

(source - http://emedicine.medscape.com/article/1004104-overview#a0104 )

PaulaO2
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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.
10-11-2012 09:08 PM
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PaulaO2 Offline
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Post: #8
RE: Your thoughts on study and titration estimates
We were posting at the same time.

All masks are designed to release the CO2 we breathe out. She is not breathing it back in.

PaulaO2
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Breathe deeply and count to zen.

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.
10-11-2012 09:10 PM
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zonk Offline

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Post: #9
RE: Your thoughts on study and titration estimates
(10-11-2012 09:05 PM)Muchosueno Wrote:  What is the EPR setting? does this apply to her?
EPR = Expiratory Pressure Relief
reduces pressure at exhale by 1, 2 or 3 com H2O but pressure cannot drop below 4
masks guides have a warning that rebreathing might occur at low pressures
10-11-2012 09:48 PM
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