New UARS patient? Standard Sleep Study NORMAL.

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
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49er
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by 49er » Sat Jul 19, 2014 7:19 am

Sludge wrote:
49er wrote:Sludge, I still would welcome your opinion but if you don't want to provide one, that is fine.
I gave my opinion in

viewtopic.php?f=1&t=99026&p=920512#p920512

referencing

viewtopic.php?f=1&t=92548&st=0&sk=t&sd= ... e&start=15

Was that not clear?
Thanks Sludge, I didn't see those links. Right now, nothing is clear. but that has nothing to do with you. And no, I didn't get drunk last night in case anyone was wondering.

Ok, my apologies to physician for getting this thread off track. Back to regularly scheduled programming.

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justinjustin
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by justinjustin » Sat Jul 19, 2014 10:09 am

Sludge wrote:
49er wrote:Sludge, I still would welcome your opinion but if you don't want to provide one, that is fine.
I gave my opinion in

viewtopic.php?f=1&t=99026&p=920512#p920512

referencing

viewtopic.php?f=1&t=92548&st=0&sk=t&sd= ... e&start=15

Was that not clear?

Sludge, I meant the real story with respect to my SDB. Other sleep docs/labs actually told me they weren't certain UARS *exists* as a valid diagnosis, which is not up for debate anymore. Also I've talked to multiple patients that have a similar experience of multiple sleep studies, surgeries, xPAPs, masks, even jaw surgeries to no avail, only to finally find answers with Dr. Krakow.

Yes, I paid $900 (PSG) + 2 x $800 (titration) + $500 + 250 for my visit with Krakow. Plus $1,000 flight and travel. Plus $2,100 for the ASV.
Grand total. $6,500.

But he diagnoses ComplexSA + UARS and my treatment with ASV and his titrated settings are giving me more relief than any CPAP/APAP/BiPAP I've used.

So yeah, I'd gladly pay $5,000 more because he figured out the *real story* for me. I'm sorry you seem rather skeptical about his value, but I can offer one powerful anecdote that he provided treatment after the failure of 3 previous sleep studies, 3 sleep doctors, 2 ENTs, 2 naturopaths, endocrinologist, 3 surgeons and other medical professionals could not.

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Sludge
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Sludge » Sat Jul 19, 2014 2:54 pm

justinjustin wrote:I'm sorry you seem rather skeptical about his value....
Why are you sorry?

I can never understand why people say that.

Anyway, what about the esophageal pressure transducer?
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Physician
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Physician » Sat Jul 19, 2014 6:28 pm

Sludge wrote:
justinjustin wrote:I'm sorry you seem rather skeptical about his value....
Why are you sorry?

I can never understand why people say that.

Anyway, what about the esophageal pressure transducer?




Why is an esophageal transducer required for the diagnosis of UARS ?

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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Physician » Sun Jul 20, 2014 1:04 am

After three days of CPAP following a normal sleep study she is about 80% better. More energy, concentration, better concentration, no napping, and far less yawning. Just plain awesome.

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Sludge
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Sludge » Sun Jul 20, 2014 2:12 am

Physician wrote:
Sludge wrote:
justinjustin wrote:I'm sorry you seem rather skeptical about his value....
Why are you sorry?

I can never understand why people say that.

Anyway, what about the esophageal pressure transducer?




Why is an esophageal transducer required for the diagnosis of UARS ?
Sludge wrote:
Physician wrote:Another question: If an esophageal probe is required for this diagnosis, then why didn't her sleep study and all sleep studies include this probe?
Becasue it is NOT required:
With respect to scoring a RERA, use of esophageal pressure is the preferred method of assessing change in respiratory effort, although nasal pressure and inductance plethysmography can be used.
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Sludge
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Sludge » Sun Jul 20, 2014 2:46 am

justinjustin wrote:Other sleep docs/labs actually told me they weren't certain UARS *exists* as a valid diagnosis, which is not up for debate anymore.
Yet, it really does not matter if UARS is a valid diagnosis or not. The key to RERAs is "arousals", and If the NPSG is scored correctly, and you're looking at ~>100 arousals for the night, then everyone should know that there's at least something underfoot. Therefore, they should not only be looking at SDB, but "sleep" as well. Consequently:
justinjustin wrote:I can offer one powerful anecdote that he provided treatment after the failure of 3 previous sleep studies, 3 sleep doctors, 2 ENTs, 2 naturopaths, endocrinologist, 3 surgeons and other medical professionals could not.
sleep studies do not fail (only the people looking at them). ENTs and surgeons only want to hack and slash, I have NFI how an endocrinologist would help (unless he was investigating "fatigue", which is a different ballgame), I could have told you about naturopaths and saved you the trip, and if the sleep doctors were running OSA assembly lines then the result(s) was (were) for a foregone conclusion.
justinjustin wrote:my treatment with ASV and his titrated settings are giving me more relief than any CPAP/APAP/BiPAP I've used.
I think ASV (particularly the ResMed version) can be an effective comfort measure.

Albeit a very expensive one.
sludge wrote:Therefore, they should not only be looking at SDB, but "sleep" as well.
barry wrote:A consecutive series of patients were included who met research diagnostic criteria for an insomnia disorder at intake; an objective diagnosis of SDB (obstructive sleep apnea [OSA]: AHI > 5 or upper airway resistance syndrome [UARS]: RDI > 15 and AHI <5); completed a full night or split-night titration PSG with standard PAP therapy; and completed a full night or split-therapy titration with ASV therapy.
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49er
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by 49er » Sun Jul 20, 2014 4:34 am

Yet, it really does not matter if UARS is a valid diagnosis or not. The key to RERAs is "arousals", and If the NPSG is scored correctly, and you're looking at ~>100 arousals for the night, then everyone should know that there's at least something underfoot. Therefore, they should not only be looking at SDB, but "sleep" as well. Consequently:
But the question is do they? I mean if sleep labs aren't looking for UARS in my area as one sleep doctor stated, what motivation would they have to investigate further regarding an extraordinary number of arousals?

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Does the drop in HI, AI, AHI mean she should be using a mask

Post by Physician » Sun Jul 20, 2014 5:14 pm

Follow up of her values.

She has been using nasal pillows, but last night she used a Mirage FX nasal mask. Her values changed last night in that her HI, AI, and AHI dropped from the prior three nights. Why ?



--------- p -- p----- p -----mask

HI        6.7 - 9.6 - 10.3 -3.4
AI        5.4 - 4.5 - 4.1 - 2.9
AHI    12.1- 14.1- 14.4 - 6.3
LEAK   0.3  - 0.5 - 0.4 - 0.5
PRESSURE 10.6 - 11.0 - 10.0 - 0.8

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justinjustin
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Re: Does the drop in HI, AI, AHI mean she should be using a mask

Post by justinjustin » Sun Jul 20, 2014 5:52 pm

Physician wrote:Follow up of her values.

She has been using nasal pillows, but last night she used a Mirage FX nasal mask.

It sounds likely that she'd been mouth breathing (possibly because of nasal congestion, or just adjusting to therapy), which can cause breathing disturbance/arousals and thus increase the AHI because the nasal pillows can't address these. With a full face mask (FFM) like Mirage, mouth breathing is managed in the closed system.

It could be other factors as well, but those are the usual suspects.

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Mask: Mirage Quattro™ Full Face CPAP Mask with Headgear
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Additional Comments: Complex Sleep Apnea, mainly CSA, with UARS. RDI of 30 w/o xPAP.

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ChicagoGranny
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by ChicagoGranny » Sun Jul 20, 2014 5:56 pm

Many factors - level of nasal congestion, stomach contents, sleeping position, drugs, alcohol ..... the mask maybe

Come again on the pressure on the last night?

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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Pugsy » Sun Jul 20, 2014 7:12 pm

Physician wrote:LEAK 0.3 - 0.5 - 0.4 - 0.5
Physician wrote:Her values changed last night in that her HI, AI, and AHI dropped from the prior three nights. Why ?
Not sure but the leak rate (from whatever cause...mouth breathing or whatever) of 0.5 L/sec equals 30 L/min and that's when the ResMed machines seem to have difficulty sensing and thus recording events. In other words the machine may have missed recording some events. It's hard to know for sure though just by this 95% number off the LCD screen. 95% numbers just mean that the leak was at OR below that number for 95% of the night. The "or below" part of the definition leaves a big open window as to how long a person might have been at a large leak level. This is where it would come in handy to evaluate the actual leak line on the software graphs. When the 95% number stays below large leak territory we know that the bulk of the night leaks were within acceptable range so maybe not so important to see the leak graph but when the 95% number is elevated into large leak territory it may or may not be indicative of massive leaking all night long. I had an occasion to have a 95% leak number of 28 L/min once but actual time spent around 28 to 30 L/min was maybe 30 minutes. The rest of the night I was around 20 to 24 L/min....pretty ugly leak graph but I was testing a new mask and didn't have the strap tension optimal so it leaked a lot. Woke me up a lot too so I wasn't surprised the leak graph was really ugly and numbers were elevated.

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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Physician » Sun Jul 20, 2014 11:08 pm

Pugsy wrote:
Physician wrote:LEAK 0.3 - 0.5 - 0.4 - 0.5
Physician wrote:Her values changed last night in that her HI, AI, and AHI dropped from the prior three nights. Why ?
Not sure but the leak rate (from whatever cause...mouth breathing or whatever) of 0.5 L/sec equals 30 L/min and that's when the ResMed machines seem to have difficulty sensing and thus recording events. In other words the machine may have missed recording some events. It's hard to know for sure though just by this 95% number off the LCD screen. 95% numbers just mean that the leak was at OR below that number for 95% of the night. The "or below" part of the definition leaves a big open window as to how long a person might have been at a large leak level. This is where it would come in handy to evaluate the actual leak line on the software graphs. When the 95% number stays below large leak territory we know that the bulk of the night leaks were within acceptable range so maybe not so important to see the leak graph but when the 95% number is elevated into large leak territory it may or may not be indicative of massive leaking all night long. I had an occasion to have a 95% leak number of 28 L/min once but actual time spent around 28 to 30 L/min was maybe 30 minutes. The rest of the night I was around 20 to 24 L/min....pretty ugly leak graph but I was testing a new mask and didn't have the strap tension optimal so it leaked a lot. Woke me up a lot too so I wasn't surprised the leak graph was really ugly and numbers were elevated.


Liters per second ? The LCD screen reads in L/min., right ?

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Sludge
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Sludge » Mon Jul 21, 2014 5:03 am

49er wrote:
Yet, it really does not matter if UARS is a valid diagnosis or not. The key to RERAs is "arousals", and If the NPSG is scored correctly, and you're looking at ~>100 arousals for the night, then everyone should know that there's at least something underfoot. Therefore, they should not only be looking at SDB, but "sleep" as well. Consequently:
But the question is do they? I mean if sleep labs aren't looking for UARS in my area as one sleep doctor stated, what motivation would they have to investigate further regarding an extraordinary number of arousals?
If they're an OSA factory?

None.
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Sludge
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Re: New UARS patient? Standard Sleep Study NORMAL.

Post by Sludge » Mon Jul 21, 2014 5:05 am

Physician wrote:Liters per second ? The LCD screen reads in L/min., right ?
Physician wrote:Her values during her first use night. She elected to attach the humidifier and use nasal pillows.

Leak 0.3 L/S
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