Newly Diagnosed Dr. wants another study. What does it mean?

Hello, new guy here!

I recently completed a split night sleep study and received the results last week. The interpreting Dr. stated the following (paraphrased some):

-A therapeutic pressure was not obtained due to persistence of obstructive events. Ideally patient should return for completion of BiPAP titration. Starting pressure should be 12/8.
-If this is not feasible, then a trial of auto titrating BiPAP with a minimum setting of 6 nad max setting of 25 with pressure support of 4 may be considered.

I currently do no have insurance due to being self employed and our insurer pulling out of the state. So, I am self pay/cash. My original split night cost me a hair less than $1,500. Doing the titration study will cost me an additional $1,300. Then since it appears the interpreting Dr. is recommending BiPAP, looks like another $1,500-2000 for a darn machine. I make good money and don't mind paying if it is necessary but don't want to just piss away money because some Dr. wants to do it. He probably does not even know I am self pay.

I asked my family Dr. who ordered the SS if it was necessary and she said yes, that I needed to do it. I have a call in to the interpreting Dr. to get his opinion based on financial situations but though I would ask those with user experience your opinion.

For what it is worth my AHI prior to CPAP was 39.2 with o2 levels dropping to a low of 80% with a mean of 89%. CPAP was started but switched to BiPAP due to persistent events. At BiPAP of 15/11 there were 2 hypopneas for a AHI of 35.2 with o2 levels dropping to a low of 91% and a mean of 95%.

Any advice for a confused fellow who is willing to spend the money if necessary but does not want to waste it? I am actually looking forward to getting a machine and getting on with this and getting my life back to normal!

Get the Auto BiPap. You are going to need the machine no matter what.
If you can't get dialed in on pressures then you can always revisit an official lab titration.

If this didn't work

TT wrote:At BiPAP of 15/11 there were 2 hypopneas for a AHI of 35.2

and assuming the bulk of the AHI is obstructive apneas

then this won't likely work...at these settings...you are going to need much more than the minimum of 6 with PS of 4.

TT wrote: then a trial of auto titrating BiPAP with a minimum setting of 6 nad max setting of 25 with pressure support of 4 may be considered.

I am not so sure the machine can get to where it needs to be quickly enough but it is a starting point. Just be prepared to change it fairly quickly.

Tell the doctor that you prefer this due to the fact you don't have insurance...explain you wish to try the titration at home and if it doesn't work out then you will revisit maybe having an in lab titration.
They just ran out of time during the split study.

It's fairly easy to auto titrate at home as long as you don't have some sort of complicating factors going on.

Check seconwindcpap.com for a gently used bilevel machine.
Target these models
Respironics....DreamStation BiPap Auto or the slightly older PR System One 60 series BiPap Auto model 760
or
ResMed....AirCurve 10 VAuto or the slightly older S9 VPAP Auto


If you have plain jane vanilla OSA...it's fairly simple.

Pugsy wrote:If you have plain jane vanilla OSA...it's fairly simple.

I've heard that before, somewhere...

MaxINTJ wrote: I've heard that before, somewhere...

Ahhhh...but not everyone has plain jane vanilla OSA but

TT wrote:For what it is worth my AHI prior to CPAP was 39.2 with o2 levels dropping to a low of 80%

TT wrote:A therapeutic pressure was not obtained due to persistence of obstructive events

Is very likely plain jane vanilla OSA.

Pugsy wrote:Get the Auto BiPap. You are going to need the machine no matter what.
If you can't get dialed in on pressures then you can always revisit an official lab titration.

If this didn't work

TT wrote:At BiPAP of 15/11 there were 2 hypopneas for a AHI of 35.2

and assuming the bulk of the AHI is obstructive apneas

then this won't likely work...at these settings...you are going to need much more than the minimum of 6 with PS of 4.

TT wrote: then a trial of auto titrating BiPAP with a minimum setting of 6 nad max setting of 25 with pressure support of 4 may be considered.

I am not so sure the machine can get to where it needs to be quickly enough but it is a starting point. Just be prepared to change it fairly quickly.

Tell the doctor that you prefer this due to the fact you don't have insurance...explain you wish to try the titration at home and if it doesn't work out then you will revisit maybe having an in lab titration.
They just ran out of time during the split study.

It's fairly easy to auto titrate at home as long as you don't have some sort of complicating factors going on.

Check seconwindcpap.com for a gently used bilevel machine.
Target these models
Respironics....DreamStation BiPap Auto or the slightly older PR System One 60 series BiPap Auto model 760
or
ResMed....AirCurve 10 VAuto or the slightly older S9 VPAP Auto


If you have plain jane vanilla OSA...it's fairly simple.

Is there a reason why you are recommending A-BiPAP vs APAP? Is it just because it is a more capable machine which may be needed or is there a specific reason? I am curious as I used a BiPAP machine for 7 years until it broke and I switched to A-PAP which has worked well for me.

TedVPAP wrote:Is there a reason why you are recommending A-BiPAP vs APAP? Is it just because it is a more capable machine which may be needed or is there a specific reason?

Yes.
2 reasons... He had a split night study...then started on cpap/apap and quickly switched over to bilevel but sounds like they ran out of time and didn't come close to finding a suitable pressure.

1...that's what the doctor suggested ...is the main reason...his suggested RX starting point can't be done with apap...they won't do PS of 4.

TT wrote:-A therapeutic pressure was not obtained due to persistence of obstructive events. Ideally patient should return for completion of BiPAP titration. Starting pressure should be 12/8.
-If this is not feasible, then a trial of auto titrating BiPAP

they got to

TT wrote:At BiPAP of 15/11 there were 2 hypopneas for a AHI of 35.2

Second reason and probably what the doctor was thinking...I am betting that he needs pressures in the upper teens and maybe exceeding 20 cm which apap can't do and at pressures in the upper teens bilevel is going to be easier to adjust to.

If EPAP 11 and IPAP of 15 still gives an AHI of 35 and it's obstructive...he's going to need a lot more pressure to get those events prevented.
No sense in spending money for apap when there's a really, really good chance he is going to need higher pressures and PS and maybe even over 20 cm pressure.

Especially since he is self pay. Best to just bite the expensive bullet once and get a machine that can do the job.

At this point we don't know that even 20 cm will do the job.

Makes sense - thanks for the clarification.
So as a general rule is seems that CPAP is generally limited to maximum treatment pressure and pressure relief of no more than 20 and 3, respectively???

xxyzx wrote:

TedVPAP wrote:

Pugsy wrote:Get the Auto BiPap. You are going to need the machine no matter what.
If you can't get dialed in on pressures then you can always revisit an official lab titration.

If this didn't work

TT wrote:At BiPAP of 15/11 there were 2 hypopneas for a AHI of 35.2

and assuming the bulk of the AHI is obstructive apneas

then this won't likely work...at these settings...you are going to need much more than the minimum of 6 with PS of 4.

TT wrote: then a trial of auto titrating BiPAP with a minimum setting of 6 nad max setting of 25 with pressure support of 4 may be considered.

I am not so sure the machine can get to where it needs to be quickly enough but it is a starting point. Just be prepared to change it fairly quickly.

Tell the doctor that you prefer this due to the fact you don't have insurance...explain you wish to try the titration at home and if it doesn't work out then you will revisit maybe having an in lab titration.
They just ran out of time during the split study.

It's fairly easy to auto titrate at home as long as you don't have some sort of complicating factors going on.

Check seconwindcpap.com for a gently used bilevel machine.
Target these models
Respironics....DreamStation BiPap Auto or the slightly older PR System One 60 series BiPap Auto model 760
or
ResMed....AirCurve 10 VAuto or the slightly older S9 VPAP Auto


If you have plain jane vanilla OSA...it's fairly simple.

Is there a reason why you are recommending A-BiPAP vs APAP? Is it just because it is a more capable machine which may be needed or is there a specific reason? I am curious as I used a BiPAP machine for 7 years until it broke and I switched to A-PAP which has worked well for me.

the sleep lab and doctor said bipap

no reason to ever get a vanilla cpap
an auto bipap can do anything a cpap can and more and better

Agree but I am trying to understand what exactly a bipap delivers over a cpap. It seems like greater pressure relief.

TedVPAP wrote:So as a general rule is seems that CPAP is generally limited to maximum treatment pressure and pressure relief of no more than 20 and 3, respectively???

Correct. Cpap/apap max pressure available is 20 and ResMed PS is 3 max (using EPR) and Respironics is 2 with Flex at 3 (they do the exhale relief differently).

Bilevel machines usually go to 25 but a few very special will go to 30 but those are for very special situations.

If the OP wasn't so far off with his AHI at 35 with 11/15...he maybe could have snuck by like you and your pressures but since the difference is so great the likelihood of being able to get by with max of 20 is pretty slim.

We can find a good auto bilevel for self pay and not have to spend $1500.

Just my 2 cents... I was gifted a few years ago a shiny like new bilevel. I felt I was doing ok on my cpap though having my pressure needs creeping up over 14was causing air in my belly. But because I had the chance, I went ahead and set up the bilevel and began to use it. The difference in the ease of breathing surprised me. I had been struggling but didn't even realize it because I thought it was how this is supposed to feel. When it is evident pretty high pressures will be needed, with this personal experience, I would think a bilevel is a good investment in the future. My bilevel settings were recommended by forum members and have thusfar needed no further adjustment.

Thank you all for taking the time out of your busy lives to reply! I sincerely appreciate it. This is all new to me and I want to get it right as quickly as possible. I am tired of my life going by me and me not being able to enjoy it. The sooner I can get on with it and get going, the better!

Another question...I just turned 50 in August and am overweight but not obese. I am 6'2" and weigh 235. I usually think of folks who need serious xPAP to be ones that are significantly overweight. Would I be considered significantly overweight and if not, what causes these issues? Is it just genetics and the way we are put together? I have had signs of OSA for many years, even back when I was not nearly as overweight. A year ago I was only 210 and still had terrible snoring where folks at deer hunting camp with me would say I would wake up gasping. I know the extra weight does not help but it is the result of stopping smokeless tobacco use, also for health reasons.

Getting old sucks sometimes!

Thanks again everyone!

I would say not significantly obese, just somewhat overwt... and it's now thought that if anything, apnea may be responsible for the gain, not the other way around, and once you have more energy you're likely to lose it anyway, so don't feel too bad about it. And good for you for stopping that bad habit, but please stop calling yourself 'old' at 50! Not applicable these days.

TT wrote: what causes these issues? Is it just genetics and the way we are put together?

Sometimes it's just Mother Nature being cruel.
I never had sleep apnea symptoms until menopause hit then everything starts to sag...the boobs, the butt, the belly and the airway tissues.
While weight might play a part it doesn't necessarily mean that it will play a significant part.
I was a skinny 110 pounds when I was diagnosed and my AHI was over 50 per hour in REM.

Just floppy/saggy airway tissues courtesy of getting older.

Sometimes it's a combination of things...small mouth...small airway to start with and then as we age and tissues start to sag...they block an already compromised airway.

It's not just for older people though...babies can get it...teenagers and get it...young adults.

Does your extra few pounds make things worse...maybe but also maybe not.

kteague wrote:Just my 2 cents... I was gifted a few years ago a shiny like new bilevel. I felt I was doing ok on my cpap though having my pressure needs creeping up over 14was causing air in my belly. But because I had the chance, I went ahead and set up the bilevel and began to use it. The difference in the ease of breathing surprised me. I had been struggling but didn't even realize it because I thought it was how this is supposed to feel. When it is evident pretty high pressures will be needed, with this personal experience, I would think a bilevel is a good investment in the future. My bilevel settings were recommended by forum members and have thusfar needed no further adjustment.

My situation is not exactly the same as yours.

But, I was recently switched to a ResMed AirCurve 10 VAUTO.
Was previously using a ResMed S9 AutoSet.

My time on the BiPAP is too limited to give an absolute opinion at this point.

Used to be we all said it was always best to get an "Auto".

My very preliminary opinion is that most, if not all, should now instead get at least a BiPAP.

Yes, Yes, I know there are probably some exceptions where an APAP might be better than a BiPAP.

And, of course, insurance will not pay for a BiPAP unless it is proven that you actually need it.

But, if someone is going to self pay anyway, I would seriously look at a BiPAP - remembering that a BiPAP does cost more than an APAP.

Well, you guys that suggested I not do the second study will be disappointed in me! After reading your opinions and thinking it through, I decided to go ahead and do the titration study. I have it scheduled for tomorrow night. My reasoning...I REALLY need this to work correctly right off the bat. I really don't want to take the time to fool around with pressures that are possibly incorrect and then working my way to the right pressure. Yeah, I am probably throwing away money but at least I will feel it is correct right out of the gate! I do value your opinion 100% though!