Did Your Titration Produce Normal Sleep and Breathing?

[ozij]

That next post is UARS--A Critical Link to Optimizing PAP Therapy Results

O.

[BarryKrakowMD]

I've added my equipment to the Profile so it shows up now.

I use the Breeze Nasal pillows and have rigged a little strap that wraps around the hard plastic mold where the pillow cushions are inserted. The straps are then brought upwards, gently, to better seal the pillows, and they have velcro ends, so i can stick them to headgear or a chinstrap near the sides or top of my head.

Recently, I've alternated with the Mirage Quattro FFM and have been very pleased with the results.

I pay considerable attention to nasal hygiene, so in addition to having zero tolerance for allergies (Flunisolide, Nasalcrom, Nasal Saline washes), I use two Breathe Right nasal strips each night with a layering effect to pull the nasal passages open.

Thanks ozij for inserted the title/link of the next post.

[Snoredog]

The long answer is coming up in another post, where I will discuss the relationships between UARS, anxiety, and erratic responses to PAP therapy.

OK, looking forward to that, meanwhile, people might do some homework with some of your previously published material:

Prevalence of Insomnia Symptoms in Patients With Sleep-Disordered Breathing
Barry Krakow, MD; Dominic Melendrez, PSG-T; Emily Ferreira; James Clark; Teddy D. Warner, PhD; Brandy Sisley and David Sklar, MD

Relationships Between Insomnia and Sleep-Disordered Breathing
Ka-Fai Chung, MBBS, MRCPsych

Breathe-Right Strips, huh?

Hey RG, why not give those a shot to see if they help your FL Runs?

By-the-by, Dr. Krakow, I think your poll would more (fair, accurate, whatever) if you asked "Flow Limitations or RERAs or RDI", since this concept may be presented in a number of different approaches.

Course, if the responses still came back zero, that would be a little disheartening.
SAG

I use BreatheRight strips nearly every night, have done so for a couple years, can't really say they reduce the number of FL's seen but I have that feature turned off on my 420e. I get a few FL's recorded on my Aflex at times (not every night).

I'm not totally convinced (yet) those FL's are associated with spontaneous arousals as Dr. Krakow suggests. I had 4 PSG's including a titration on Bi-level and it didn't do a thing for my spontaneous arousals, think my last PSG showed I had 27-29 of those per hour while on therapy. Granted my last PSG was back in 2001, but I know the tech that titrated me the last time was very experienced and was trained at Standford which is less than 60 miles away.

I don't consider the FL's runs I have to be any problem at all (based upon the number seen when using my 420e reports), even with 1FL off it still records them if present. We have seen quite a few 420e reports here where FL runs were a train wreck. But we have seen here reports from 420e's and Remstars where those FL's were present even with high pressure. My pressure is not high, I have to keep it under 9 cm or CA's start showing up. I cannot use a Resmed Auto, it will run up to any maximum pressure set, same for the 420e if 1FL is enabled.

I'm a believer in finding your ideal sweet spot with xpap therapy (either with pressure and/or machine type) that results in restful sleep, by that I mean fewest FL's, Hypopnea, Apnea and Zero CA's seen on any report accurate or not.

I'll remain open on the FL - spontaneous arousal association (I've said before here amazing the patient is having FL's at 18cm or greater pressure).

Dr. Krakow suggests in one of the other posts having a greater spread (>4 cm) with Bi-level IPAP/EPAP improves UARS. Wonder how they missed that finding in my PSG's, I still have the bi-level titration (somewhere).

Are we to assume here (and/or have you seen it in your lab) where the spontaneous arousals reduce when a patient is put on B-Level with a wider spread?

if Dr. Krakow's research is correct, wouldn't we see a drop on the EEG of those arousals?

If UARS is associated with a sagging palate as some suggest, are we to assume UARS is eliminated with a UPPP?

[GumbyCT]

Dr. Krakow, I think your poll would more (fair, accurate, whatever) if you asked "Flow Limitations or RERAs or RDI", since this concept may be presented in a number of different approaches.

Interesting enough during my last visit at the West Haven, CT VA sleep clinic (while reviewing my data generated by an evaluation version of C1Chart2D w/i Encore 1.8.49), when I asked the doc what the difference between Variable Breathing & Flow Limitation - she told me "Mr. Gumby, you are getting too technical. That info on there for doctors only."

In an earlier statement she informed me I was seeing her because of her expertise!!! Yet refused to answer any questions I asked during that visit. She also insisted that "Encore is 100% accurrate" or she "wouldn't use it"

You can bet the ranch her and Mr. Gumby won't be meeting again.

[Snoredog]

Dr. Krakow, I think your poll would more (fair, accurate, whatever) if you asked "Flow Limitations or RERAs or RDI", since this concept may be presented in a number of different approaches.

Interesting enough during my last visit at the West Haven, CT VA sleep clinic (while reviewing my data generated by an evaluation version of C1Chart2D w/i Encore 1.8.49), when I asked the doc what the difference between Variable Breathing & Flow Limitation - she told me "Mr. Gumby, you are getting too technical. That info on there for doctors only."

In an earlier statement she informed me I was seeing her because of her expertise!!! Yet refused to answer any questions I asked during that visit. She also insisted that "Encore is 100% accurrate" or she "wouldn't use it"

You can bet the ranch her and Mr. Gumby won't be meeting again.

[Guest]

Some Clarifications.

UARS and SAs. There is no question in my mind that some spontanous arousals (SAs) are actually a misnomer, applied only because the sleep lab did not use esophageal manometry or pressure transducer to correctly link the arousal with a respiratory event.

BUT, I'm not suggesting that all SAs are caused by UARS. Most likely some SAs are part of the cyclic alternating pattern (CAP) process. I am not a CAP expert, but again, there can be no doubt that "bad" CAP is highly active in some patients who are reporting a poor response to PAP therapy.

So, you can go to the bank on the UARS and SA connection; it's just quite variable as to how much they are linked in any given patient. To reiterate, I've seen lots of patients tested at another lab where the diagnosis was spontaneous arousals and no breathing events. We diagnosed them with UARS and they improved. Did the SAs drop. Probably. Did they still have SAs. Probably. Last, some SAs are truly thought to be normal.

UPPP. There are no data, convincing, at least to suggest that UPPP is a consistently viable treatment for UARS. And, remember as much as one-third of UPPP patients will have subsequent difficulties in using PAP therapy. Unfortunately, UPPP until recently was widely touted and widely over-used, but now the sleep medicine community is reining back on it and discouraging many patients from undergoing the procedure except as more of a last resort.

[RipVW]

My sleep study was useful in that it diagnosed my sleep apnea. But, the results/titration were way off. A year later, after finding this forum, getting software and reviewing my data, I realized that I was not receiving therapy. Not until I purchased an auto-titrating APAP did I discover my real therapy needs and begin to get therapy results.

[jskinner]

BarryKrakowMD,

Welcome to the group. I for one welcome the addition of sleep professionals to the group, I think its very valuable. We have had a number come and go since I have been here and some times I have felt because we have pushed them away. You must understand that many of us here feel like we havn't had very good support from the medical community. I encourage you to stick around, if you can stand us

I know some in the group won't like the fact that a book is being pushed but personally I think thats ok as long as the member is providing useful information.

I think its interesting that BiPAPS are being used more now. After my week trial with one it was clear to me that they where _way_ more comfortable. However my comfort was not enough to be switched to one

Dr BarryKrakowMD, the new A-Flex seems to be a lot closer to Bilevel in exhalation releif than C-Flex. Can you comment weather this might be as good as Bilevel for most people? Maybe its too new to have been studied much yet?

Thanks, -James

[BarryKrakowMD]

I think APAP machines are programmed to provide some expiratory relief, so I assume the addition of a Flex function would add to it. I've not used it or prescribed it, but I suspect there is a way to either monitor it in the lab or otherwise to measure the gap. Regardless, the more important issue would be the shape of the expiratory limb of the airflow curve, because the more smooth, round or elliptical, would likely predict a larger gap than CFlex, although obviously depending upon the patient.

[roster]

Time must be going through some warps today. I am sure this thread was at the top of the list this morning and now again.

Good to see the old boy Snoredog again.

Well, gotta go now. Since it is December 7, 2007, I am going to sell some stocks while the S&P500 is at 1504. My lucky day!

[jskinner]

Good to see the old boy Snoredog again.

Agreed

[kteague]

Good to see the old boy Snoredog again.

Agreed

JSkinner - good to see you too! Gonna start a thread and let us know how you're doing?

[JohnBFisher]

Dr Krakow,

It is interesting that you imply that you see Spontaneous Arousals connected with what may be breathing events. I've talked with several lab technicians, managers and doctors about Spontaneous Arousals. I have a neurodegenerative disorder that impacts my cerebellum and brainstem (Sporadic OPCA). MANY years ago, I found CPAP no longer seemed to meet my needs. The sleep tech doing a new titration study noted many spontaneous arousals. These seemed to be reduced when he switched me to BiPAP. The sleep technician, the lab manager and the doctor were very clear that a spontaneous arousal could not be connected with flow limitations, or other respiratory events.

[Since that time, about 18 years ago, the number of spontaneous arousals have increased, as have the number of central apneas. My current nurologist moved me to an ASV about a year ago. However, he cautioned me that sleep dysregulation is often an issue when the brainstem is involved. And I've noted that even with my ASV unit, I often have nights of very, very light sleep. Fortunately I get enough days of good sleep to make up for those nights where I don't feel rested.]

I don't doubt that you probably see too many reports where the Spontaneous Arousals may have been scored too high. I am just surprised, since the definition appears to be very clear. Perhaps it is that some flow limitations can not be readily measured by the various sensors.

By the way, THANK YOU for contributing to this Forum. Though we try to help others as much as possible, we welcome experienced professionals who reach out to help us all learn more about sleep and the management of sleep disorders! Thank you!

[OutaSync]

Whatever happened to RosemaryB and Mindy? They were so active in 2007.

[rested gal]

Dunno. Nice to see you, though.