Got new sleep Dr - how to add 'specialist' to team?

[CPAPnerd]

So I'm one of those that have dialed in my Airsense 11 to as good a therapy level as i can get based on the numbers and how I feel. AHI averaging 1-2, no leaks, CPAP of 14, EPR of 3, flow limitations knocked down a good bit. BUT, still do not awake feeling good/great (remember when you used to make up and felt charged and ready to go?). Plus sleepy during day and often needing naps.

I have new Dr and will probably be doing a new sleep test in a couple of months. He seems to listen and care pretty well, but just concerned that he represents the typical industry sleep Dr in that he might only be charged with and concerned with helping patients achieve minimum therapy/metric levels (see above). He probably does not have much if any at all experience with helping patients achieve higher (dare I say close to optimum) therapy levels.

Is there such a thing, as in sooooo many other medical fields that have specialists consult with generalists, where a specialist sleep Dr could consult with my typical sleep Dr on testing protocol, reviewing results, machine options?

Thanks!

PS: Or other advice?

[Sleeprider]

There is no requirement that you submit to a new sleep test. A sleep test is used for diagnosis of sleep apnea and is useless as an optimization tool. Titration tests are an optional means of determining an "effective" pressure for therapy, but again, is not intended for optimization. If CPAP therapy is optimized to be as good as possible, but you're still affected by fatigue of sleepiness, the problem likely resides some place other than your CPAP therapy. With or without sleep apnea and treated sleep disordered breathing, your complaints are among the most common health complaints. It can relate to many things other than your CPAP therapy, including sleep hygiene, diet, hormones, irregular schedule, fitness, etc. I'm not saying you can't further optimize your CPAP therapy, but as you accurately point out, it's unlikely to come from a sleep specialist. Feel free to post a chart or two if you want some ideas or confirmation therapy is good.

[CPAPnerd]

OK, thanks for the reply. So let me ask because I've often wondered, once a patient has obtained proper usage/compliance, low AHI, low leaks, no complaints about aerophagia, etc, what if any other metrics or data should be evaluated for proper therapy? 

Attached are two screenshots, one of whole night, and one of a about 90 minutes or so, please note flowrate spikes every so often. I assume that the airflow graph should be as smooth as possible except for REM periods, hence when mine looks like it needs a shave due to the irregularities and spikes, I assume there's opportunity for improvement, both in the metrics but more importantly in how I feel. It almost seems as if my body is 'competing' with the PAP on even a low level all night long, trying to figure out which one is in control. That may sound crazy, but that's where I'm at in my technical understanding and experience.

I appreciate your input! Looking forward to your thoughts.

[Sleeprider]

The only thing that stands out to me is an unusually long inspiration time compared to shorter expiration time. The 95% flow limitation is zero, so to see why the CPAP is measuring this anomaly, we would have to look at a random zoomed image of 3 - 4 minutes where the flow rate chart shows the individual waves and transition. Everything on the chart looks good, and the only SpO2 drop is at 7:30 and is not associated with events. As you said, the therapy is overall very good with appropriate time, minimal interruptions and good metrics.

[CPAPnerd]

See two new screenshots please, probably more than 3 minutes each, but there is some 'junk' there. This is where I'm not confident my conventional CPAP/APAP equipment has the functions/settings to iron these out? I think, that if person A has a slight amount of junk, they may not be affected that much, but person B who experiences the same amount of junk, might very well affected. This is perhaps where the quantitative world will simply have to catch up with the qualitative side, and believe me, I love me some quantitative numbers such that you can eliminate subjectivity, but like with lots of stuff, people report it subjectively and then science/medicine figures out a way to quantify it.

[Sleeprider]

Everything looks normal to me in those zoomed shots. You have a good strong expiratory flow that rebounds to a near-zero flow ahead of inspiration. Normal, but it gives the Resmed fits as it doesn't know how to score the null flow. Junk is junk. I have more than my share in charts, so your therapy looks pretty good for a CPAP. If you were working with something like the Vauto bilevel, we could do more. Have you ever tried autoset pressure? What were the results? With pressure at 14 and EPR 3, you get a consistent 14/11 pressure which is hard to fault. The OA events are probably changes in position or something similar, because there is no flow limitation leading into it.

[CPAPnerd]

I guess everyone is going to have some 'junk in the trunk' huh? 

Yes, tried autoset. Initial titration 10 years ago said 7-11 APAP, which worked OK. But again, not great. Ive since adopted the approach of ironing these events out before they pop up. I think the EPR has been the most helpful tool on this device.

Not tried bi-level, but if 3 EPR on a Autosense does some good, then perhaps a 3, 4, or 5 PS on a Vauto would do even gooder? I was able to convince new sleep Dr that if we do new sleep test, that probably no use in wasting time on CPAP/APAP and that we should go straight to bi-level to see if we improve some of the quantitatives but as much or more the qualitatives, if possible. In fact, he said we would have to do the first 2 hours no PAP for insurance purposes, even though we both know I have documented OSA. Perhaps they can gleen something from this 2 hour period before the bi-level portion of the test.

Feel free to share your thoughts on anything. I'm attaching image of my avatar in hopes of getting it updated. Dont know where else to upload it to the forum.

Again, thanks for all your help.

[Sleeprider]

The path to bilevel does not lie through sleep tests. It is entirely dependent on you working with your "treating physician" to move to something that works better. If you continue to experience the symptoms you describe with CPAP, then that is a point of discussion with your doctor to move your therapy to bilevel. Many members have recently been through this, and honestly, it's the story of my own therapy. My story is far to long to recite, but my last sleep test was in 2008 and I moved to bilevel in 2015 and being "of age", Medicare approved a new one last year. A good example of this is in Deborah K's thread where I explain it more at length, and she moved from CPAP to bilevel. I know you think you have to jump through a lot of hoops, but it really comes down to having a good working relationship with your doctor (not a sleep specialist) to find the best solution for you. You have done great work in self-titration, and maybe you just need a better tool? Take some time to skim this thread and pay attention to the method in the madness. https://www.apneaboard.com/forums/Thread...to-Bilevel

[CPAPnerd]

"Bilevel is the CPAP everyone should have." You nailed it! I personally believe there's a WHOLE lot of less than desirable sleep quality going on because of this.

As far as getting one, used market is one option, and will consider if I have to. If I go through my family Dr, and he wrote script for one, insurance would send me to sleep Dr, which I now have new one. Never had one for 10 years of therapy, another crime IMO. And sleep Dr and insurance will almost assuredly have to have another sleep test from me, and like you said, request, get denied, appeal, and request again, and play the game.

Thanks again!