Doc Says "Don't Worry About the Numbers!"

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
JDS74
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Re: Doc Says "Don't Worry About the Numbers!"

Post by JDS74 » Sun Jul 05, 2015 5:47 am

Looking closely at the titration study information that the OP provides, he experienced 21 central apnea events during the study. 8 occurred at a pressure of 10 cmH2O.
The study said in summary when describing the statistics:
RESPIRATORY PROFILE. The patient was presented with the incremental application CPAP. As anticipated, he required very high pressure 20/14cm, significantly higher than what the auto Pap was delivering. For comfort, he was switched to bi-level positive airway pressure to accommodate the higher pressure. He also did relatively well on 11 cm, but the higher pressure of 20 cm was superior. Relevant pressure with duration, AHI, RDI, mean oxygen saturation is as follows:
There doesn't seem to be a connection between added pressure and occurrences of central events as shown in the data. Notice that the OP had zero centrals at a pressure of 18/14 cmH2O and all the events were hypopneas for an AHI of 11.6, much better than he is now getting. At a fixed pressure of 11 cmH2O as mentioned in the summary above, the OP had zero centrals, and an AHI of 10.0.

This would suggest that either there is a real (but minor) central issue that is somewhat exacerbated by the higher pressure or, because of the amount of time awake during each pressure change, the centrals occurred close to the sleep-awake transitions. Notice that at the 11 cmH2O pressure, the OP did not wake up during the period. At the pressure of 20/14 cmH2O, the OP woke up for a total of 40.5 minutes out of total duration of 170.5 minutes (about 23.7% of the time.) That's a lot of sleep fragmentation.

With the centrals averaging 30 seconds, it may be better to consider a lower IPAP pressure and a narrower range such as 18/14 cmH2O.

As always, get on board with your doctor about any changes to the pressure. You report feeling somewhat better and the centrals don't seem to be doing anything really harmful since, in the titration study, the average SpO2 level stayed above 94% more than 99% of the time. He doesn't report any SpO2 data at home. Perhaps getting a recording pulse oximeter would be helpful in collecting more data, evaluating the effect of the centrals, and contributing to his feeling that this is OK right now but could be better with a little tweaking.

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Re: Doc Says "Don't Worry About the Numbers!"

Post by palerider » Sun Jul 05, 2015 1:21 pm

JDS74 wrote: You report feeling somewhat better and the centrals don't seem to be doing anything really harmful since,
I think, however, most people would say that a CAI of 19 isn't really a very good thing.

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Re: Doc Says "Don't Worry About the Numbers!"

Post by tedburnsIII » Sun Jul 05, 2015 2:27 pm

Titration appears to be somewhat of a mess.

He was indeed having centrals during titration but as was stated above, he was awake for a good part of the study when the CA's occurred.

Perhaps he should be titrated again SLEEPING, if not in the lab, by using an overnight pulse oximeter.

Do note that comments said that he did well at 11cm, but 20cm far superior, but if he was awake @20/14m it doesn't make sense to me, as titration did not provide an optimum pressure according to the Guidelines at any time. I would not give the titration much weight.

One needs to be asleep during a titration to benefit from its results.

Perhaps Doc felt numbers weren't that important over how OP feels, and that RDI as high as 15 constitutes an 'acceptable' titration under the Guidelines assuming other perquisites are met.

Perhaps ASV might be appropriate? I wish someone who knows far more than I do would comment about whether OP's case raises such an issue.

Thank you in particular for your post, JDS.
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JDS74
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Re: Doc Says "Don't Worry About the Numbers!"

Post by JDS74 » Sun Jul 05, 2015 3:49 pm

I did suggest that this might be a case of pressure induced complex sleep apnea. BUT, there is not enough data to make the leap to a change to an ASV machine at this time. Also not known is the interaction with his insurance company. Some companies require a serious trial at a bi-level machine before they will approve payment for an ASV machine.

We should be concentrating on how the OP can get better therapy.

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bsokal
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Re: Doc Says "Don't Worry About the Numbers!"

Post by bsokal » Sun Jul 05, 2015 4:52 pm

JDS74 says: "there is not enough data to make the leap to a change to an ASV machine at this time."

What additional data is needed to make a decision whether to switch to an ASV machine?

Based on what I have read I will seek the opinion of another sleep doctor "who worries about the numbers!". I will also follow the advise of JDS74 to "get on board with your doctor about any changes to the pressure."

Thanks to all who responded to my post - it is very appreciated!

JDS74
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Re: Doc Says "Don't Worry About the Numbers!"

Post by JDS74 » Sun Jul 05, 2015 8:26 pm

To get to an ASV machine you will have to demonstrate a failure of the bi-level machine you now have.
Failure means that you are very compliant in usage and the machine is failing to provide adequate therapy to address your needs.
To do that you will need at least a couple of months of data including several days of SpO2 data.
That will be necessary to convince your doctor to order, and have the insurance company agree to pay for, an ASV titration study. Then, if that study supports moving to an ASV machine, you will be on your way.

Many insurance companies require that a significant effort be made to make the bi-level machine work. What that might mean is up to them.

To get this done, your doctor has to be on board. Check with your doctor to see if he will accept SleepyHead reports or must have reports from the manufacturer's software. So, get appropriate software (if it is not SleepyHead) and use it to generate supporting reports. Get a recording pulse oximeter and start getting SpO2 data to establish whether or not you are having significant desaturations. In your sleep study, it seems as if you didn't but things can be different at home. The sleep titration study was only a few hours in a strange place but at home, you live with the equipment daily in a very familiar place.

My doctor prefers Encore reports but does accept SleepyHead reports as well.
My doctor also wanted to compare his oximetry readings with my oximeter so that he could rely on that data.
I used a CMS50F oximeter from Cooper Medical until I got and installed a system from Respironics that integrates the data directly into the Encore and SleepyHead reports. With a little fiddling, CMS oximeter data can be integrated into SleepyHead reports as well. There is an import function for doing that and others are better able to advise you on how that all works. External oximeter data cannot be integrated into either Encore or ResScan software reports. They will remain separate.

EDIT:

My apologies for not mentioning this sooner. If you get an ASV machine, your AHI will likely not change much. The ASV CPAP machines treat central events, they don't prevent them. So, you central even that lasts 30 seconds will still occur and the difference will be that it will end after 10 seconds because your machine will enter ventilator mode and breathe for you for the next 20 seconds unless you initiate a breath before that time.

What may happen, is that you will feel better in the morning after a better night's sleep.
What you will have to cope with is a machine that varies your pressure not from 14 to 20 cmH2O but from 14 to 25 cmH2O between breaths and some folks have great difficulties coping with that. The chances of Aerophagia are increased by the higher pressure. Your co-pay will increase dramatically. Your current machine is a roughly $1,000 machine the ASV machine will be about $3,500. The co-pay will increase in proportion.

If/when your doctor orders an ASV titration and it comes back with similar numbers to your current one, your insurance company won't pay for the upgrade. it will be your dime. When my doctor ordered an ASV titration study for me, the numbers came back with a fairly low number of central apnea events. I got a scrip for one anyway, fully expecting to pay all if it myself. Fortunately, I had an original diagnosis of complex sleep apnea from the Mayo Clinic, the scrip from my doctor, and documentation of 3 years compliance with an average use time of over 7 hours and only 3 day without usage (one of those was spent in the ER, one was spent in the sleep study, and one on a trip when I forgot to pack my power supply.) My insurance company paid for my machine but I fully expected to have to pay for it all.

If you end up there, then I recommend getting one from an on-line DME and not from your local DME. I did. The local price will be on the order of $7,000. Then you will have the problem of what to do if the unit fails either during warranty or after the warranty is over. An on-line purchase will mean no support from the local DME. Unless you want to go commando and sleep without any machine at all while yours gets fixed, you'll need a backup machine (I bought one.) That's your dime as well.

Take a deep breath and go through the process. Work with your doctor to get your therapy optimized. You may very well end up on an ASV machine. It all takes time.

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Re: Doc Says "Don't Worry About the Numbers!"

Post by Cokomo » Wed Jan 06, 2016 5:45 am

Does anyone know what happened with this OP? Thread just petered out.

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Julie
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Re: Doc Says "Don't Worry About the Numbers!"

Post by Julie » Wed Jan 06, 2016 5:48 am

As most eventually do. Were you looking for some personal info or answers?

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Re: Doc Says "Don't Worry About the Numbers!"

Post by Cokomo » Wed Jan 06, 2016 6:02 am

Curious as how to reduce clear airway events as I am dealing with them on a much lesser scale. Found this thread and became interested.

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Julie
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Re: Doc Says "Don't Worry About the Numbers!"

Post by Julie » Wed Jan 06, 2016 6:06 am

Well if you're having a few when falling asleep and another few just prior to waking, they would not be considered abnormal or in need of fixing. If you're having very many throughout the night, you might want to consider an ASV machine, but prior to that, why not download (free) Sleepyhead to see what's actually going on?

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Re: Doc Says "Don't Worry About the Numbers!"

Post by LSAT » Wed Jan 06, 2016 6:55 am

Cokomo wrote:Curious as how to reduce clear airway events as I am dealing with them on a much lesser scale. Found this thread and became interested.
Difficult to eliminate Clear Airway events. How many are you getting and what is your AHI. If you are noticing the events you must be looking at your daily detail. Unless you are looking at Dozens..in large clumps, forget about them.

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Re: Doc Says "Don't Worry About the Numbers!"

Post by bsokal@optonline.net » Wed Jan 06, 2016 8:31 pm

I am the one who started this thread back in July 2014. One a Resmed CPAP machine were:

AHI : 19.19

Obstructive Index: 6.23
Hypopnea Index: 0.23
Clear Airways Index: 11.44

After a home study and two in lab sleep studies where I went from a CPAP machine to a BiPap machine to my current Resmed ASV machine my last week of readings were:

AHI : 4.34

Obstructive Index: 0.00
Hypopnea Index: 1.62
Clear Airways Index: 0.00

I changed sleep doctors for the last sleep study and he prescribed the ASV machine. My first doctor told me to "Not to worry about the numbers". I am glad I did not listen to him and changed sleep doctors. My central sleep apnea issue appears to have resolved with my ASV machine.

So my advice is to be persistent and don't be discouraged - it took me about 8 months to find the right machine. I found the members who responded to my questions to be great - better than my original doctor in fact.

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Re: Doc Says "Don't Worry About the Numbers!"

Post by Cokomo » Thu Jan 07, 2016 6:36 am

Thank you for responding. Do you feel much better since knocking out the clear airway events? Were they pressure related in your opinion? I once had a Dr. who said my untreated AHI of 131 was knocked down to 33 with APAP (4-20) and that I had made "great progress" and was perfectly content to leave it at that.....Needless to say he was dumped and I found Pugsy.

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Re: Doc Says "Don't Worry About the Numbers!"

Post by SewTired » Thu Jan 07, 2016 8:38 am

bsokal wrote: So I am at the point do I resign myself to an AHI of 18 or do I see another sleep doctor and get a second opinion? Also what should an ideal AHI I should shoot for - 10 or under or 5 and under?

Thanks in advance for any suggestions.
I'd say wait until you see your doc. He may have a goal to meet. Write down your questions so that you don't forget any of them, but specifically, why is 18 acceptable? It could be that he wants you simply to get used to the machine rather than blasting you with the pressure. Too many people abandon their xpap.

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Re: Doc Says "Don't Worry About the Numbers!"

Post by archangle » Thu Jan 07, 2016 10:56 pm

bsokal@optonline.net wrote:I am the one who started this thread back in July 2014. One a Resmed CPAP machine were:
Congratulations on getting self empowered and escaping the evil clutches of an incompetent member of the medical mafia.

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