Newby Question - Titration test last night, Sucked!

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Re: Newby Question - Titration test last night, Sucked!

Post by SW 2.0 » Fri Aug 28, 2015 6:17 am

I will be meeting wit the doctor today at lunch, but in the meantime I was able to get a copy of my results in advance. Here's how it turned out - would appreciate any thoughts, you guys have a lot of experience in this, I have NONE. What bothers me most is while OSA and Hypopneas went down, CSAs went from 1 previously to 21 with CPAP, so they went up significantly. And sleep efficiency went down from my initial sleep study, from 83.5% down to 81%.
========================================================
Please find enclosed the final report of a complete nocturnal titration polysomnogram performed on 8/24/2015.

SLEEP ARCHITECTURE
The total time in bed was 422.0 minutes; the total sleep time was 345.0 minutes. Wake after sleep onset was 40.0 minutes. Sleep efficiency was 81.8%. The Sleep Latency was 37.0 minutes. The REM Latency was 68.0 minutes. While asleep, the patient spent 1.9% of the time in N1 sleep, 63.9% of the time in N2 sleep, 8.8% of the time in N3 slow wave sleep, and 25.4% of the time in REM sleep. Supine REM sleep was achieved.

RESPIRATORY PARAMETERS
Nasal CPAP was started at cm H2O and was increased up to a maximum pressure of 16cm H2O. BIPAP was initiated for continued events, as well as patient comfort. A pressure of 14/10cm H2O appeared to be optimal.  A wide ResMed AirFit N10 mask was used. Heated humidity was added for patient comfort. The patient's baseline O2 saturation while awake was 95% and the lowest O2 saturation observed was 87%. The percentage of time with O2 saturation above 90% was 99.45%. Mask leakage was present at higher pressure levels.

LIMB MOVEMENTS/CARDIAC EVENTS
The periodic limb movement index was 17.6 per hour. The average heart rate during sleep was 64.6 bpm. Occasional PVC’s were observed during the study.
IMPRESSIONS:
Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS) intractable to CPAP, with good response to BIPAP - 327.23
Periodic Limb Movements of Sleep (PLMS) – 327.51

RECOMMENDATIONS:
The patient should be set up with nasal CPAP per sleep lab protocol unless otherwise indicated.
Mask re-fit.
Treatment of PLMS as clinically indicated.
Avoid driving or operating heavy machinery if tired.

TECHNICIAN COMMENTS:
Pt did not want a fullface. Resmed airfit P10 fit well, good leak. Pt disliked .Resmed mirage fx. Resmed Airfit N10, great fit and leak. Pt chose Airfit N10. Cpap titration was tolerated well until pt awoke. Pt reached optimum pressure of 20/14cm. Around 0300, pt complained of being hot and the pressure too high, reduced pressure to 14/10 for pt comfort .mild hypopneas were still present / snoring eliminated. Supine Rem achieved.

Time Entered EPOCH# Comment
9:55:38 PM 7 EYES CLOSED
9:56:09 PM 8 EYES OPENED, LOOK STRAIGHT
9:56:34 PM 9 BLINK 5X
9:56:44 PM 9 LOOK LEFT/RIGHT
9:56:55 PM 10 LOOK UP/DOWN
9:57:09 PM 10 SNORE 3X
9:57:25 PM 11 GRIT TEETH/SWALLOW
9:57:40 PM 11 BREATHE THROUGH MOUTH
9:58:01 PM 12 BREATHE THROUGH NOSE
9:58:23 PM 13 BREATH, HOLD BREATH 10 SECONDS
9:58:48 PM 13 PARADOXICAL BREATHING
9:59:05 PM 14 FLEX LEFT FOOT
9:59:12 PM 14 FLEX RIGHT FOOT
9:59:19 PM 14 FLEX BOTH FEET
9:59:27 PM 15 LIGHTS OUT (GOOD NIGHT)
9:59:28 PM 15 tir addinf snore mic
9:59:33 PM 15 position to supine
10:30:39 PM 77 Spo2 94, Hr 67, RR 20, stage W, Position S, Snoring NONE, Cpap 5 , Leak 35
10:50:01 PM 116 cpap 6 for arousals
10:58:23 PM 133 cpap 7 for arousals
11:00:38 PM 137 Spo2 94, Hr 62, RR 16, stage N2, Position S, Snoring NONE, Cpap 7 , Leak 39
11:07:34 PM 151 cpap 8 for arousals
11:26:31 PM 189 cpap 9 for hy
11:26:35 PM 189 increasing slowly due to sensitivity
11:30:40 PM 197 Spo2 92, Hr 63, RR 16, stage N2, Position S, Snoring NONE, Cpap 9 , Leak 41
11:30:42 PM 197 HY NOTED
11:43:03 PM 222 cpap 10 for hy
11:46:12 PM 228 cpap 11 for hy
11:51:23 PM 239 cpap 12 for hy
11:56:30 PM 249 CPAP 13 FOR HY
11:57:36 PM 251 SUPINE REM ACHIEVED
12:00:38 AM 257 Spo2 95, Hr 70, RR 16, stage R, Position S, Snoring NONE, Cpap 13 , Leak 74
12:19:09 AM 294 TIR FOR HIGH LEAK/ MAB DUE TO MOUSTACHE
12:22:25 AM 301 NOCTURIA
12:24:55 AM 306 PT BACK IN BED / SUPINE
12:30:37 AM 317 Spo2 97, Hr 63, RR 16, stage N1, Position S, Snoring NONE, Cpap 13 , Leak 49
12:48:57 AM 354 CPAP 14 FOR HY
1:00:38 AM 377 Spo2 95, Hr 59, RR 18, stage N2, Position S, Snoring NONE, Cpap 14 , Leak 48
1:04:06 AM 384 CPAP 15 FOR PLMS
1:22:59 AM 422 CPAP 16 FOR HY
1:31:37 AM 439 Spo2 96, Hr 63, RR 12, stage R, Position S, Snoring NONE, Cpap 16/14 , Leak 99
1:32:03 AM 440 BIPAP 16/14 DUE TO HY
1:34:12 AM 444 16/12 FOR PT COMFORT
1:49:29 AM 475 17/12 FOR HY
2:00:38 AM 497 Spo2 95, Hr 62, RR 16, stage N2, Position S, Snoring NONE, Cpap 17/12 , Leak 54
2:15:30 AM 527 18/13 FOR HY
2:29:12 AM 554 EPAP 12 FOR PT COMFORT
2:30:38 AM 557 Spo2 94, Hr 80, RR 12, stage N2, Position S, Snoring NONE, Cpap 18/12 , Leak 60
2:34:58 AM 566 EPAP 13
2:40:25 AM 577 POSITION TO THE RIGHT
2:54:57 AM 606 IPAP 19 FOR HY
3:00:40 AM 617 Spo2 94, Hr 61, RR 18, stage N2, Position R, Snoring NONE, Cpap 19/13 , Leak 88
3:22:55 AM 662 20/14 FOR HY
3:30:37 AM 677 Spo2 95, Hr 68, RR 20, stage R, Position S, Snoring NONE, Cpap 20/14 , Leak 95
3:41:24 AM 699 POSITION TO SUPINE
3:47:00 AM 710 TIR/PT CALLING
3:48:44 AM 713 TOR/ PT COMPLAINING OF HOT ROOM TURNED ON FAN
3:49:10 AM 714 WILL INCREASE IPAP WHEN PT FALLS TO SLEEP
3:51:42 AM 719 TIR/ PT COMPLAINING OF HIGH PRESSURE
3:51:57 AM 720 DECREASING PRESSURE TILL PT FALLS TO SLEEP
3:56:24 AM 729 POSITION TO THE LEFT
4:00:37 AM 737 Spo2 95, Hr 66, RR 16, stage W, Position S, Snoring NONE, Cpap 16/10 , Leak 60
4:30:39 AM 797 Spo2 96, Hr 63, RR 12, stage N1, Position L, Snoring NONE, Cpap 14/10 , Leak 47
5:00:04 AM 856 LIGHTS ON (GOOD MORNING)
===================================================================

Greatly appreciate any insight anyone might have - it's all new to me.

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Re: Newby Question - Titration test last night, Sucked!

Post by Sir NoddinOff » Fri Aug 28, 2015 9:49 am

That was a pretty good titration compared to some of mine. You'll get used to the mask and the pressure, give it time.

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Re: Newby Question - Titration test last night, Sucked!

Post by Pugsy » Fri Aug 28, 2015 9:56 am

Looks like you qualify for a bilevel machine due to pressure needs. Good news about bilevel machines is that they are all full data machines.
Don't worry about the centrals at this time...they may or may not be significant and a bilevel machine is probably what would be advised at this stage anyway.
Also don't worry about the slight drop in % of sleep efficiency. That's not unexpected for a titration study and the difference is statistically not that great.

Most likely either a ResMed bilevel machine (newest is called AirCurve 10) or a Respironics PR System One BiPap. There are other brands but these 2 are the main players in the bilevel market.

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Re: Newby Question - Titration test last night, Sucked!

Post by SW 2.0 » Fri Aug 28, 2015 12:26 pm

Awesome, thanks. You're right on - they are setting me up with the Aircurve 10. Hope it's good.

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Re: Newby Question - Titration test last night, Sucked!

Post by Pugsy » Fri Aug 28, 2015 1:01 pm

SleepyHead seems to sometimes have a little trouble with reporting the settings on the AirCurve models. Minor thing mostly in the statistics machine settings area. The AirCurve models were released after the latest SleepyHead version was released. Should you find that happens to you and you want to verify with ResScan you can also use ResScan software as long as you are using a Windows computer (or a Mac with Windows on it). ResScan doesn't have a Mac version but Sleepyhead does.

I predict you will like the AirCurve and become a ResMed snob like a lot of us here. They are nice machines. I became one myself...I have used both Respironics and ResMed machines and while I do fine with Respironics my overall preference in general for various reasons is ResMed...so we laugh about those of us who used to use Respironics (I did for 3 years) and tried ResMed and became "ResMed snobs". Several of us here who actually have used both brands.
You will also like the way it works at the higher pressures in the bilevel department. I use a bilevel myself but more out of just because it's what I like in terms of comfort than anything else but to me comfort equals better sleep and better sleep has always been my number one goal.

Higher pressures are going to be a challenge no matter what the machine that is delivering them but the challenge won't be so big with the bilevel machines.

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Re: Newby Question - Titration test last night, Sucked!

Post by SW 2.0 » Fri Aug 28, 2015 2:15 pm

Sounds good, I hope it works out. While I was there, I founded out I needed pre-authorization from insurance, so I have to meet with the DME (ABC Healthcare) next week to get the equipment. I think I'm going to ask for the Phillips WISP Nasal mask. When I did the titration study, I was using the N10, but the WISP seemed slightly more comfortable just now. Of course it's hard to tell for certain without any air blowing through it (real world scenario).

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Re: Newby Question - Titration test last night, Sucked!

Post by SW 2.0 » Fri Aug 28, 2015 2:17 pm

I GREATLY value you all of your feedback - it's very helpful. Thank you for that! I'm still so uncertain about all of this.

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Re: Newby Question - Titration test last night, Sucked!

Post by SW 2.0 » Mon Aug 31, 2015 11:29 am

Well, I could not get the equipment Friday, things were a little delayed. I called Anthem to ensure the DME is on their in-network list of approved DMEs (they are), but they also told me they needed to pre-authorize any solution before it could be provided, which meant their doctors had to review the titration study results and concur with the proposed solution (BIPAP / AirCurve 10). So for now until that is done, everything is on hold.

I guess we'll see what happens next. Meanwhile, I still wake up with the typical morning headaches and get the normal daytime fatigue sleep apnea causes.

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Re: Newby Question - Titration test last night, Sucked!

Post by SewTired » Tue Sep 01, 2015 9:37 pm

Whether you start with a single pressure or not, make sure you get an auto CPAP . Your needs will change. I also find my pressure needs change depending on how high the pollen allergies are going, the fires in the west, or nothing at all.

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Re: Newby Question - Titration test last night, Sucked!

Post by SW 2.0 » Wed Sep 02, 2015 6:26 am

Thanks SewTired. What they are giving me is a BIPAP machine called an Aircurve 10. I am picking it up today after lunch.

Does anyone have any experience with that machine? I found it online, but I don't know if it has ramp up capability. E.G. - starts off with a low pressure while you try to get to sleep and then gradually increases to the appropriate pressure, which for me is going to be 14 / 10 (thus the BIPAP function) based on the titration study results.

Also, on their website there are different Aircurve 10 models, AirCurve 10 ASV, AirCurve 10 Auto, AirCurve 10S, and Aircurve 10 ST. I have no idea which one they plan to provide.

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Re: Newby Question - Titration test last night, Sucked!

Post by Pugsy » Wed Sep 02, 2015 7:44 am

The Aircurve 10 model line does have a ramp function if needed.
The different models do different things....if you have plain jane vanilla OSA with no complicating factors I suspect you will get the "plain" bilevel that doesn't do the extra stuff mainly for centrals that the others do.
Probably you will get the AirCurve 10 S which is a fixed bilevel and won't auto adjust or the AirCurve 10 VAuto which has an auto adjusting mode.
AirCurve 10 S has cpap mode and bilevel fixed mode
AirCurve 10 VAuto has cpap mode and bilevel fixed mode and bilevel auto adjusting mode.

If you had an issue with centrals then you would likely be getting the AirCurve 10 ASV.

But yes...there is a ramp function available if needed on all of them.

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Re: Newby Question - Titration test last night, Sucked!

Post by SW 2.0 » Wed Sep 02, 2015 7:59 am

Pugsy,

Thank you, very helpful.

Regarding Centrals - CSAs went from 1 CA when I did the sleep study, to 21 CA's with CPAP when I did the titration study (what is that, >2,00% increase?). I found that very odd, but the doctor said that can happen when your body has not had CPAP before and is not used to it, and not to worry. I have no idea if he is right on that.

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Re: Newby Question - Titration test last night, Sucked!

Post by Pugsy » Wed Sep 02, 2015 8:20 am

Your doctor is correct...it (that central thing) can happen but even if it does sometimes the centrals will go away with time as the body adjusts. It's sort of a breathing instability and has to do with carbon dioxide levels.

Depending on what you read...maybe 10 to 15% of the people who start CPAP will have this issues with the centrals pop up. Now sometimes it's a minor issue and sometimes it's a major issue...and 21 centrals over 4 hours would be approx 5 per hour and that's maybe a minor issue. If yours was over 6 hours...even less of an issue.

Now sometimes this "issue" will go away with time and sometimes it won't and sometimes it needs a special machine to help. Usually the first thing that is tried is bilevel like you are most likely going to get because sometimes that is enough to keep the centrals down to manageable numbers while the body is adjusting (this is of course assuming that your centrals are indeed causes by cpap.
Sometimes a "plain" bilevel machine will do the trick in terms of not causing too many centrals to crop up.
Due to the cost involved for those high end machines that do specifically treat the centrals...unless the centrals are present in huge numbers (10 plus per hour, every hour, etc) insurance companies often require that a person try the less costly alternative.

Now remember when you get your machine that some centrals being flagged is normal because having a few centrals is normal. So don't panic if you see a few centrals.
Some of them are probably what we call sleep onset centrals and a handful of those centrals isn't a problem.
Some of them might be awake/semi awake breathing irregularities getting flagged as a central but they aren't real centrals. These machines can't tell if you are awake or not and they just measure air flow so sometimes they get fooled by awake breathing.

Hold your breath for 10 seconds...that's a cessation of air moving but the airway is open..that's essentially what a central is...no air movement but the airway is open.
It's not a big deal even if it is "real" as long as there's not a truckload of them happening and/or you can't stay asleep because of them.

Centrals aren't a cause for panic...even if someone does end up having enough of them that they present a problem then it's just a matter of moving up to the machine that deals with them but they don't always need that level of therapy.

Just get your machine and watch the reports (be sure to get the software and I do suggest ResScan in addition to SleepyHead) and watch the centrals. If they are present in large numbers and don't reduce on their own with some time...then the doc can decide on what to do but he is correct...sometimes they will reduce on their own with time.

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Re: Newby Question - Titration test last night, Sucked!

Post by SW 2.0 » Wed Sep 02, 2015 8:38 am

Thanks Pugsy,

I just emailed the DME and asked which model I will be picking up from him this afternoon, here is his reply:

"You are receiving the Resmed S10 Aircurve VPAP Auto. Your prescription is calling for a spontaneous mode, which this device will provide. We provide the VPAP Auto model since it is no additional charge to you or your insurance to receive the advanced model. This will allow access for the doctor to prescribe three different modes for therapy (CPAP, Spontaneous, and VPAP Auto). Based on the study and his interpretations, the doctor is prescribing the spontaneous mode on this device. Each manufacturer patents an algorithm into the way treatment is provided by the device. Resmed is the worldwide leader in sleep therapy, and statistics have proven this device provides a better treatment for this mode, and is the preferred device used by the Dr. I have attached the patient manual for reference if needed. Thanks"

I guess that's good?

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Re: Newby Question - Titration test last night, Sucked!

Post by Pugsy » Wed Sep 02, 2015 8:58 am

It's great.
Spontaneous mode is what I call fixed bilevel.
It's great they are giving you the Auto bilevel...nice to have if for some reason it is determined that you maybe need different pressures at different times in the night. Like for me...my OSA is worse in REM sleep so I sometimes would need much higher pressures during those REM time frames but I didn't want to use those higher pressures all night.

You can go to the apneaboard and request the provider/clinical manual because it is unlikely that the DME will include it in the box.
http://www.apneaboard.com/adjust-cpap-p ... tup-manual

I suggest ResScan (if you have a Windows computer) in addition to SleepyHead because SH has a little trouble with the settings reporting on the AirCurve machines. SleepyHead was written a few months before the AirCurve machines were released. The basic data is still correct but what SH says the settings are is sometimes a bit whacko. Mainly use ResScan if something needs verification or you want to ask the doctor about something because he won't be familiar with SleepyHead.

Send me a private message if you want ResScan.

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