New Sleep Study - MORE Confused

[cmpman1974]

Last night, I had my sleep study at my new doc's office.  It was a bit concerning as even though I've been on BPAP 15+ years,  the new office did a split study.  I spent two hours on no machine at all which seems insane for a long-term user.  Furthermore, they tried to titrate me on CPAP for a few hours.   I told them upfront they are literally wasting their time with that, but they insisted it's 'normal protocol'.  The pressure got up to 18-20 on CPAP and it was impossible to tolerate as the mask leaking couldn't be stopped.  Upon much insistence, they moved me to BPAP-S.  

I went in trying to determine if BPAP ST-A was needed at all.  Hard to answer that when the sleep tech didn't even know what it did.  They kept insisting a BPAP-S can do anything an IVAPS does.  That alone is very concerning.  Obviously that is way off unless someone knows how to crack the machine to change modes cancelled out currently.  I don't think they understood what IVAPS, ST-A or ASV did too well.   

They also said it's against policy to set EPAP at anything more than 4 units below IPAP.  My current settings are 16 IPAP / 8 EPAP.   If PS is what constitutes ventilation need, how can you always reach what is needed if dead set against going above 4.  I was told I do not need supplemental O2 at the proper BPAP-S setting.  The end setting titrated was 18 IPAP / 14 EPAP.  They said it resolved all events and O2 levels were good.   I have not spoken to the doctor yet obviously to confirm final settings.

My CheckmeMax O2 showed very different results from the oximeter used there.  Keep in mind some of this study was without even using a machine, on CPAP, or sub-optimal settings.  I don't know yet how long I was on 18/14 as I don't have the report.

My big question is this.....the previous sleep doc insisted I had CO2 retention and possibly OHS.  PS is THE method to increase ventilation and expel more CO2.  My venous blood testing usually showed CO2 in the 28-33 range.  This is above the 27 threshold they like.  PS drives Tidal Volume, which could be the reason my median Vt was 700-800 mL every night.  Given this data, why would an office reduce PS from 8 to 4 now?  Higher EPAP is said to improve oxygenation, but wouldn't the 50% decrease in PS cause further CO2 issues if truly a problem?    In the end, it seems things again come down to verifiable proof.  Following standard titration protocol is OK, but don't you need to factor in a patient's issues as well?  

How can someone titrate for ST-A if you don't even know what it does fully?   I'm not saying I truly need this mode, but knowing how it works is important.  I was told the requirement for supplemental O2 is TEN minutes under 89% for the night.  I thought it was 5 min > under 88% under Medicare.

[Sleeprider]

Why do you use these quacks?

[cmpman1974]

This was said to be a highly accredited facility.  I have no way of knowing upfront what will or won't happen.   I really expect a physician to be leading the charge as to what and how testing / titration needs to be done.  This is especially true when they are given large amounts of historical data to review. That only seems right.   If I find out, the optimal pressures were only used for 15 min of the study and that's why no O2 is needed, I will be pretty upset.  Tiny snapshots are a silly approach to this. I am guessing my O2 watch is far less accurate than their devices. At least if it would've been a full BPAP titration study the entire time, I would've had a better O2 baseline to compare to.\

I will see what the report shows and make a final opinion from that.

[Plmnb]

Your story with your test sounds somewhat similar to my experience.  In my case my sleep docs were fully on board with what I told them about my machine needs and concerns.  Unfortunately, the sleep lab seemed like nincompoops.  They had the printed sleep test instructions from the doctor yet they didn't seem to have a clue.  It clearly stated I was to be titrated on STA and they tried to titrate me on lesser machines. The tech looked like a deer in the headlights when I questioned her on the machine type they were supposed to measure me on.  Even the DME was very uninformed about my STA machine. 

How they ended up prescribing iVAPS i don't know.  I tried to find out from the sleep lab and all they told me was these were the settings my study showed I needed.  

I plan on having a long talk with my doctor in May.

[cmpman1974]

Your story with your test sounds somewhat similar to my experience.  In my case my sleep docs were fully on board with what I told them about my machine needs and concerns.  Unfortunately, the sleep lab seemed like nincompoops.  They had the printed sleep test instructions from the doctor yet they didn't seem to have a clue.  It clearly stated I was to be titrated on STA and they tried to titrate me on lesser machines. The tech looked like a deer in the headlights when I questioned her on the machine type they were supposed to measure me on.  Even the DME was very uninformed about my STA machine. 

How they ended up prescribing iVAPS i don't know.  I tried to find out from the sleep lab and all they told me was these were the settings my study showed I needed.  

I plan on having a long talk with my doctor in May.

Yes sounds very similar to my stuff.  I guess these facilities get paid no matter what so no big deal if rules aren't followed.  It just means do another multi-thousand dollar polysomnogram later and generate more $$$. At minimum, the individual titrating a patient should know all types of machines and when they are of benefit to a patient if in that field.  If someone has a 16/8 pressure currently, the first question asked should be why to get a solid understanding of why the Pressure Support was set at that level to begin with.

I do not feel getting rid of that supplemental O2 is the best idea yet.

[cmpman1974]

So the question is how did they know ventilation was OK when EPAP was increased from 8 to 14. It did exactly as this article indicates:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5720219/

It seems to be a multi-faceted issue in which each area needs to be reviewed to see if goals are accomplished. If there are no CO2 measurements, no understanding of elevated CO2, no ABG testing after, tough to know if things are right. I believe the higher EPAP reduced my Tidal Volumes some. It 'probably' cut down on hypopneas/RERAs (we'll see). Is this going to bite me on the back end with elevated CO2 and more symptoms though?

[Sleeprider]

Here is the titration protocol recommended by Resmed for VPAP-S, and Philips for BiPAP-S.  Thinking back to your technician's assertion that it is their policy not to use pressure support greater than 4.0 cm, note both Resmed and Philips recommend starting at PS 4.0 and increasing IPAP for other events (i.e. hypopnea, RERA, snores, comfort). Note especially that for SpO2 less than 90% the protocol recommends increasing PS and to follow sleep lab protocols for supplemental O2.   Now knowing the major manufacturers both have this in their protocol, how much do you trust the technician has any basic knowledge of his craft. These protocols are consistent with accepted sleep apnea medical practice standards. I'd look it up, but arguing with your medical team is a waste of breath and effort.

Resmed:




Philips:

[cmpman1974]

I agree with everything you said Sleeprider.   To think a patient came to a new office with a solid history of PS between 8-10 and have that completely ignored makes little to no sense.  The first thing that comes to mind for me would be there must be a reason and try to understand more what that is. 

I really have to see the polysomnogram details to make final judgment on the process.  I want to see AHI stats, RERAs, O2 numbers, sleep staging, etc.  Most of all I want to see how much time was spent on each pressure and results.  Since 50% of the study was 'wasted' with pointless things such as no machine at all and CPAP, I imagine the time blocks will be compressed for the pressures attempted.  I equate it to a mechanic charging me for the time they took to go out to lunch somewhere instead of fixing my vehicle. 

Unless increased EPAP greatly overweighs increased PS for improved oxygenation, I have a difficult time believing it solved all my issues.  I specifically remember the doctor making a comment that my Mv and Vt may actually be a little too low to ventilate as well as I need.  So what does the tech do.....reduce PS, reduce Vt.    I guess I was just shocked when any facility had such a strict rule on PS despite BPAP treatment.  If you can get PS of 3 using EPR on CPAP, why limit PS to 4 on BPAP?  I understand BPAP allows higher pressures than CPAP, but it's like you're disabling a part of the treatment.  I even informed the tech I had a history suggestive of NMD (never diagnosed) and that's why I was moved to BPAP originally.  It didn't seem to click.  Obviously, there were some big disconnects between what I presented, my history and goals.   I'm not too thrilled about breathing against a 14 EPAP, but I'll see.  

The titration report should show me if the Checkme Max O2 watch has any validity at all.  I am quite curious.  There's no doubt the oximeter finger sensors used (nonin-type) are light years better than these rings/non-medical devices.

I have been on 16/8, 17/9, 21/11 in the past.  Attached is a report from a 2019 titration.  It really makes you ask yourself how an 18/14 pressure solved oxygenation issues when they were so poor a few years ago.  These titrations for each sleep study very clearly indicated despite pressures used, O2 desaturation wasn't remotely solved.  It's easy to take the # of min under 88% divided by the number of minutes I was titrated at that specific pressure level and multiply that figure by 480 min approx (8 hrs). This would guesstimate roughly total min under 88% for a given night. I know it's WAY more complicated in real life due to sleep staging, sleep position, etc.  No pressures attempted w/o supplemental O2 have got me anywhere near an acceptable O2 level for the night in the past. It's glaringly obvious in the second sleep study in 2021, AHI, RERAs, snoring was controlled at many pressures, but the concern was O2 would not go up.

[Sleeprider]

Higher EPAP is associated with better oxygenation, while higher pressure support improves ventilation to reduce CO2. Since your tech is not monitoring PCO2 the criteria that should have applied are hypopnea, RERA and snores. The test therapy detail seems to show they were using significant pressure support if I'm reading it right. The underlined 43 minute trial at 18/10/0 suggests IPAP 18, EPAP 10, backup 0, and this resulted in no apnea which is typical for you, but 4 minutes of 43 was below 88% SpO2. Overall the test shows a mean SpO2 of 88% and a minimum of 73%, so if that does not qualify for supplemental oxygen I'll be curious to know what does. Your consistently very low SpO2 and inconsistent AHI at very high bilevel pressures really stand out as major issues. I don't think you can rely on what the tech told you as being representative of your test protocol or results.

[cmpman1974]

Again the two titrations I posted were from my old sleep medicine doc's office dating 2019 and 2021.  These were not what the current office / tech were referring to with the new proposed pressure/therapy.  However, it's clear as day there is no way an 18/14 pressure I was on a few days ago alleviated all the previous issues I showed year after year after year.  If I lost tons of weight between then and now, possibly.  I'm about the same health wise (maybe a little better).  The idea I don't need O2 seems absurd unless the previous office's testing equipment was completely inaccurate for 10+ years.

It's as obvious as can be, no one bothered to look at the ten years of sleep studies I presented at my initial appt.  If they did, it would be clear these approaches were already used and the problem still exists.   It blows my mind.

The crazy part is the study that had 18/10 underlined is the one the doc at the time decided to put me on 24/14 pressure moving forward (done in April 2021). I never understood why that choice was made based on data alone. It's not like it brought me to an ideal O2 level. AHI was good under most options. PS was similar across most titrated levels. Sigh.. The doctor first tried to get me to use an ASV machine that year as they titrated me on that the last few hours. Almost NO apneas, especially centrals, but I was put on an ASV. Wouldn't you know it...insurance denied immediately. The doc said OK just stay on your BPAP-S at 24/14. 1 week later I called and said I cannot tolerate these crazy pressures. They pulled me back to 16/8. it's been like an endless circle for years.

You are correct my old sleep doc used consideriable Pressure Support on most titration tests. This new tech at the new sleep office locked me in at a PS of 4 as I was told the physicians don't like it when they go higher. They lost me at hello on that comment. Sometimes we have to step back and ask ourselves if any of the big picture makes a bit of sense.