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Watchout for "accredited sleep labs" that are not so

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Expand view Topic review: Watchout for "accredited sleep labs" that are not so

Re: Watchout for "accredited sleep labs" that are not so

Post by So Well on Mon Feb 20, 2012 3:19 pm

rocklin wrote:Hi avi

1. You are constantly hitting your upper limit, and when you do, that's where the apneas are bunched up.

Your software is telling you that it thinks your unit needs more headroom.

2. Your software is also saying that it doesn't believe that 7 is a number you should use. Other than your start-up, from your charts (just the two) it appears that your machine uses a much higher level than 7 for it's baseline stenting.

3. Do you sleep much of the night on your back? Full-face masks and sleeping on your back is a bad combination. You can train yourself to sleep most of the night on your side.

________________________________________________________________________

From my own experience, it's better to set a higher "floor" (minimum pressure). I'd give 9 or 10 a try.)

VPAPs are forever closing the barn door a full minute too late. You need to set a floor that stents your airway adequately throughout the night.

Once you establish that number (through trial and error), you can carefully experiment with other parameters.

And, yes, if you need the higher pressures, a relief of "3" isn't enough.


.


I agree with this except I would set the min pressure at 12.

Some of you have written that for pressures at 14 or above your doctor titrates and prescribes BIPAP. Sounds like a good rule of thumb.

Avi, How did you do over the weekend? Sorry about all the crap you are having to endure.

Re: Watchout for "accredited sleep labs" that are not so

Post by rocklin on Fri Feb 17, 2012 3:09 am

Hi avi

1. You are constantly hitting your upper limit, and when you do, that's where the apneas are bunched up.

Your software is telling you that it thinks your unit needs more headroom.

2. Your software is also saying that it doesn't believe that 7 is a number you should use. Other than your start-up, from your charts (just the two) it appears that your machine uses a much higher level than 7 for it's baseline stenting.

3. Do you sleep much of the night on your back? Full-face masks and sleeping on your back is a bad combination. You can train yourself to sleep most of the night on your side.

________________________________________________________________________

From my own experience, it's better to set a higher "floor" (minimum pressure). I'd give 9 or 10 a try.)

VPAPs are forever closing the barn door a full minute too late. You need to set a floor that stents your airway adequately throughout the night.

Once you establish that number (through trial and error), you can carefully experiment with other parameters.

And, yes, if you need the higher pressures, a relief of "3" isn't enough.


.

Re: Watchout for "accredited sleep labs" that are not so

Post by chunkyfrog on Thu Feb 16, 2012 10:37 pm

Thank you Avi, for the "heads up".
The need to check out a site before submitting to a test is most definitely a good idea--one that might not occur to everyone.
As expensive as these tests are, one would expect some basic standards of comfort and cleanliness.
When we are expected to sleep, conditions need to be directed to that end.
A facility that 'phones it in' needs to be avoided.

Re: Watchout for "accredited sleep labs" that are not so

Post by HoseCrusher on Thu Feb 16, 2012 10:28 pm

Avi, You may find that your apneas are better controlled if you raise your minimum pressure. Since your maximum is at 16, you may want to consider setting the minimum to 12.

As you have pointed out, this may be difficult to breath out against, so keep your EPR at 3. To get started you can set a 5 or 10 minute ramp starting at 7.

It also looks like a little higher maximum pressure may also help, but you will find out more about that during your next sleep study.

Think about raising the minimum. It may not completely knock out everything, but it may lessen their duration. I think this also results in improved restful sleep.

Re: Adventure in La La's Land

Post by avi123 on Mon Feb 13, 2012 3:50 pm

DrBucky wrote:
avi123 wrote:
archangle wrote:.


ResMed doesn't require distilled water in cleanable tubs from their website:

"If you have a standard humidifier tub, it is recommended that you use distilled or deionized water. If you have a cleanable tub, tap water is fine for everyday use.
Do not use: bleach, alcohol, chlorine or ammonia-based solutions; moisturising, antibacterial or glycerine based soaps; and water softening and unapproved descaling agents."

The point of distilled water is to prevent bacterial growth. Since you can dismantle the types of tubs they use for sleep studies, this is a non-issue.


Question:

What about the theory that,

1) Plain faucet water carries an organism by the name of Mycobacterium avium (MAC).

2) In the humidifier chamber the water with this organism is made into an aerosol, and we inhale it deeply into our lungs, that's where the problem may result. "So if you come down with a cough, let's say, and you go to your doctor, and he looks at you, and he says, well, it may be TB or something, and he'll do tests for all those things, and don't find anything. And you say, but I'm still coughing, he or she may not be testing for the right thing because it could be a low-grade cough that persists for months, you feel lousy, weak, perhaps breathing difficulties, particularly when exerting. That's a good reason to point the finger at the possibility of Mycobacterium avium pulmonary disease. It's very under-diagnosed."

Are you a qualified Doc or a scientist to repute this theory? Notice that it does not deal with Bacterial growth.

Re: Adventure in La La's Land

Post by DrBucky on Mon Feb 13, 2012 1:30 pm

avi123 wrote:
archangle wrote:Didn't we have this conversation just the other day?



What conversation?

My original post was on a very important subject that most Sleep Clinics are NOT accredited as such. But you find out about it only after you go there.

Last week I ended up in a Sleep Clinic run by one of the most respected Neurological Center in my area but did not have all rooms with Climate control thermostat in each room. My room which was located at the end of a hall, had temperature of below 70 F and no thermostat. Also, none of the Slimline humidifiers hoses had any insulation on them, not to speak about Climate Controlled lines. In addition, they use faucet water in their humidifiers instead of distilled water. So I could not fall asleep and left by 2:30 a.m. If they dare charging me for the test I will report to Medicare about the crappy situation there, and let's see what happens.


ResMed doesn't require distilled water in cleanable tubs from their website:

"If you have a standard humidifier tub, it is recommended that you use distilled or deionized water. If you have a cleanable tub, tap water is fine for everyday use.
Do not use: bleach, alcohol, chlorine or ammonia-based solutions; moisturising, antibacterial or glycerine based soaps; and water softening and unapproved descaling agents."

The point of distilled water is to prevent bacterial growth. Since you can dismantle the types of tubs they use for sleep studies, this is a non-issue.

Meaning of Flow Limitation

Post by avi123 on Mon Feb 13, 2012 1:06 pm


DreamDiver, in your post above you posted that you are not sure what Flow Limitation is about. Please check the following and do you agree with me that my Flow Limitation might be the reason for my S9 Autoset raising the pressure right away before dealing with Obstructive events?

Dr. Michael Berthone Jones, Resmed's chief designer of their APAPS, also said that Resmed Autoset machines deal first with snoring, next with flow limitation (=curve flattening), and only afterwards with apneas (without raising the pressure above 10 cm if it turned out to be a Central event).


Dr Barry Krakow about Flow Limitation:



A reminder that for all practical purposes, the following three terms are interchangeable:

• UARS (upper airway resistance)
• Flow limitation
• RERAs (respiratory effort-related arousals)

UARS as Mini-Suffocations :

First and foremost, let's look at an analogy in cardiology to put to rest the nonsense that UARS does not exist or is somehow not important. We all know that asystole (heart stops) is bad, just as we know apnea (breathing stops) is bad. But, in cardiology, for decades we've known there are many other cardiac arrhythmias producing irregular heart rhythms, and we don't sit back and say, "well it's not asystole, so it must be OK." For decades, unfortunately, that practice is in fact what many physicians were taught or conditioned to believe, "it's not apnea, so it must be OK." Indeed, to this very day, I still see patients who have been to sleep doctors who told them their sleep study was OK because it didn't show apneas.

But, as we like to say, “a little choking is still choking,” therefore I think it is reasonable to state that each of the various forms of sleep-disordered breathing (apneas, hypopneas, UARS) reflects some degree of “suffocation.” Apnea is the most concrete form as the patient awakens choking or gasping, whereas UARS is probably equivalent to a “mini-suffocation,” which while asleep I imagine produces an unpleasant sensation but not choking.

UARS is not Mutually Exclusive of Hypopneas or Apneas

Please appreciate then that UARS is simply on the continuum of breathing events. To complete our analogy, UARS represents a more subtle form of breathing irregularity (or as some say pulmonary dysrhythmia). It is not mutually exclusive of apneas or hypopneas. You can have all three types of events when you are diagnosed with sleep-disordered breathing (SDB). In fact, the most common type of SDB shows all 3 components in varying proportions during the sleep study.

You would think though that apneas are more important than UARS events, right? Well, maybe. Don’t forget that UARS events, like apneas, are also frequently associated with sleep fragmentation and therefore unequivocally associated with daytime sleepiness and fatigue. We have seen patients with severe UARS (e.g. RDI > 40), who unequivocally have more sleepiness than say a patient with a moderate degree of apneas and hypopneas (AHI =20). That is why RDI (apneas + hypopneas + UARS) is more valuable when diagnosing and treating your condition than AHI.

To repeat, it is critical to realize that nearly all patients with OSA also have a UARS component on their diagnostic sleep studies, but if the sleep lab doesn’t use the proper respiratory sensors, they will not see it: "what you don't look for, you will not see!"

Good FL numbers. It's not so much good numbers; it's normalized airflow, because it is not so easy to count UARS events. Still, you can find a way to count flow limitation events, and you certainly want to reduce them as much as possible. There are data from Rapoport's group that suggests that an RDI consisting only of UARS (FLs, RERAs) in the range of 15 to 20 is clinically significant, so a number lower than this level should be and usually is the minimum to shoot for. In our lab, we occasionally get some patients below 5, but it's the lab environment, which I think in and of itself prevents the "perfect" titration.

UARS is one of the primary reasons that many SDB patients do not achieve an optimal response. As I describe at length in my book, it is a human tendency to "normalize" behaviors, which over time prevents us from obtaining the best possible response to PAP Therapy. If you are so used to fatigue and sleepiness, having suffered for so many years, then how could you possibly discern what a normal level of sleepiness and fatigue should be? Instead, (and I know this from my own trials from CPAP to APAP and finally bilevel), when you experience some improvement, the tendency is to create a new "normal" and wrongly assume that this is "as good as it gets."

Well, it's not as good as it gets if the UARS component of the SDB hasn't been treated, because there is still more to treat. Undoubtedly, most of the members of this forum recognize the fine-tuning and tweaking that's needed to manage mask leaks, mask comfort, mouth breathing, humidifier settings, and nasal congestion, just to name a few of the issues that must be regularly attended to enhance the PAP response.

Notwithstanding, in my clinical experience, I have found that resolving the UARS component of SDB is in the top tier of factors that frequently must be addressed to achieve optimal results, especially so among patients whose regular use of PAP therapy has not yielded the desired effects. "



Any thoughts on this?

Re: Adventure in La La's Land

Post by avi123 on Mon Feb 13, 2012 10:03 am

Lizistired wrote:My sleep lab had temp control. I froze my but off and didn't sleep well because of it. They lowered the temperature be cause my head was apparently sweating and they were losing the EEG readings.
When I went for the titration I asked for extra blankets. Much better!
Have you tried raising your pressure?
DreamDiver makes some excellant points. Your charts are scary. I hope you get some help with them.



Reply:


Yes, last night I raised the pressure to 16.0 cm but kept the min pressure at 7.0 cm for the meantime.

Here are the results:


Image


Image


I agree with DreamDiver that my upper pressure should be raised even higher than 16 cm. The problem is that with these Resmed's CPAPs and APAPS I get only up to 3 cm of EPRs to reduce the exhale pressure, which is not enough. The solution is a BiPAP.

It turns out that the Tech who did my titration a year ago loused me up when she prescribed me a CPAP with pressure of 5 to 7 cm, thus, I lost a year of treatment..

See it here:


Image


As to your posting of: My sleep lab had temp control. I froze my but off and didn't sleep well because of it. They lowered the temperature be cause my head was apparently sweating and they were losing the EEG readings.
When I went for the titration I asked for extra blankets. Much better!


In my case the problem is with the temp of the air that goes into my lungs and not necessarily my body temp. So even if I pile lots of blankets on my self, as long as the inhaled air is below 70 F, I can't fall asleep like that. I used to be able in the past when I was younger. A reminder: I am older than your dad by 7 years.

To DreamDiver: you asked about Flow Limitation. Please check the next post below which I dedicate it to it:

Re: Adventure in La La's Land

Post by Lizistired on Sun Feb 12, 2012 11:26 pm

My sleep lab had temp control. I froze my but off and didn't sleep well because of it. They lowered the temperature be cause my head was apparently sweating and they were losing the EEG readings.
When I went for the titration I asked for extra blankets. Much better!
Have you tried raising your pressure?
DreamDiver makes some excellant points. Your charts are scary. I hope you get some help with them.

Re: Adventure in La La's Land

Post by avi123 on Sun Feb 12, 2012 11:04 pm

Thanks DreamDiver!

Re: Adventure in La La's Land

Post by DreamDiver on Sun Feb 12, 2012 10:12 pm

avi123 wrote:Any thoughts?
First, Don't panic. You're doing the right thing to go get a new PST. I'm sorry for your curernt horrible experience. This may be a good lesson for others. Scope out the room you'll be using ahead of time. If it doesn't meet your requirements refuse to undergo the PST before they even hook you up. Find another sleep lab. If you have to get an appointment to view the rooms a day or so before to make sure, do so. It's your money and your health insurance. You have to be satisfied, and I cannot think of any reason why they would deny you a preview of where you'll be resting your head the next night.

Second, my doctor says to drink plenty of water during the day, but stop drinking or eating anything a few hours before sleep, except enough to properly swallow any nighttime prescriptions. Stop drinking alcohol. It increases AHI. Don't eat sweets or anything just before bed. In fact, don't eat sweets except very occasionally. They're just bad for you.

They say 'Eat breakfast like a king, lunch like a prince and supper like a pauper'. According to some, this may help establish a better sleep hygiene. It's helpful for GERD and LPRD, too. I think of 'supper' as short for 'supplemental meal'. Truly, you are 'breaking your fast' when you eat breakfast if you only eat a light supper. If you go to bed each night by midnight, stop eating or drinking anything by nine pm, or even eight. That might help with the getting up to pee all night. These are suggestions my doctor gave me. They seem to help, me, so unless your doc indicates otherwise, maybe they'll help you.

Third, the charts... If these were my charts, the first thing I would see is that my current therapy is ineffective. I'd see I was having a lot of both open-airway and obstructive apneas, that my large leaks are fairly under control and that I'm constantly hitting the upper pressure limit I've assigned to my S9. I'd also notice that my pressure climbs almost immediately to the upper limit of fifteen at the beginning of each subsession, never even lingering close to the lower pressure limit of seven. The first thing I'd assume is that my lower limit is way to low and even my upper limit is also way too low. I see a lot of flow limitations, and since I don't know much about these, I'd be curious how they might be affecting my therapy, so I'd ask the doc about them. It almost looks like my lower pressure should be 15 and my upper pressure should be even higher - maybe 20, just to see how high it wants to go. However, I'm not a doctor, and these pressures are considerably higher than the average person's pressure. It makes me question whether I should be on BiPAP or perhaps even another type of xPAP altogether, especially with so many events even on CPAP. Since I'm not an expert, I'd be very glad that I've got a PST scheduled for next Tuesday.

If I've lost weight since starting CPAP therapy, my needs may have changed. I'd ask my sleep doc about that.

I think I can assume from this chart example I've gotten up four times to pee during the night.

Of course, the above is what I'd be thinking if these were my charts.

One last thought I have is about the humidity settings. Many of us on this forum have found that very high humidity actually closes up the sinuses, making it almost impossible to breathe. It seems rare that humidity at the highest setting would actually keep the sinuses clear. I wonder how much the high humidity is affecting your flow limitation. (I hope someone else wiser than I will chime in.)

I'm glad you've found a new sleep lab that suits your needs. Sleep techs tend to be very helpful if you're courteous. Bring your own hose, mask and hose cover or even two hose covers if you aren't satisfied with theirs. Bring ear plugs and even your own extra pillows if you need them. I don't think they'll object.

I wouldn't worry about whether the water is distilled. If I were used to 75 degrees room temperature at night for sleeping, I'd certainly ask for that. Personally, we keep the thermostat at 62 degrees. I've never been to a sleep lab where they didn't give you control over room temp.

Good luck.

Re: Adventure in La La's Land

Post by avi123 on Sun Feb 12, 2012 6:06 pm

DreamDiver wrote:@avi123, It looks to me like you thought you were posting to a different thread, when i fact you started a new thread. Hence the confusion and light responses.



Hi, DreamDiver. I decided to try a Sleep Clinic different than the one I did the PSG a year ago. It has an Accreditation symbol by the AASM when I looked at their web site. But once they placed me in my sleep room I found out that the room has no thermostat. How that facility could be accredited if not all rooms have their own climate control? The temp there was less than 70 F for sure. And they use 9' long Slimlines with no insulation sleeve. I am very sensitive to the air temp going into my lungs. At home my room is at 75 F constantly and I set the humidifier on #6. Last time I measured the air temp coming out my mask at home, it was 81 F.

So I left that clinic b/c I could not fall asleep. And I got no report from them. They charged Medicare $1,780 for it but got approval for $415, and my BCBS Medigap paid $244 on it.

On Tuesday I am slated to do the PSG titration at my previous clinic in a climate control room. If this outfit will not get insurance payment from Medicare, then I will be ready to pay from my pocket. I need to find out what's going on with my treatment. I sleep OK for 7 hours from midnight till 7 a. m. after taking one 10 mg tablet of Zolpidem (generic Ambien). However, it takes me till noon the next day to get rid of my Residual Excessive Sleepiness. IMO, it's not the Zolpidem that causes it but the Max pressure on my APAP needs to be set higher to treat those obstructive and flow limitation events. The pressure is now set at 15 cm. See the results:

The following is the worst case I ever had, and I have been CPAPing for a year:


Image



Image
Image


Yes, I have Nocturia but it does not bother me to fall back asleep right away.

Any thoughts?

Re: Adventure in La La's Land

Post by DreamDiver on Sun Feb 12, 2012 1:06 pm

@avi123, It looks to me like you thought you were posting to a different thread, when i fact you started a new thread. Hence the confusion and light responses.

Re: Adventure in La La's Land

Post by nanwilson on Sun Feb 12, 2012 9:09 am

You really do think you are privileged, don't you. They didn't have climate control in my room, they didn't have distilled water..........and you claim if they charge you for the appointment you will complain to insurance. YOU left, they didn't chuck you out, it was your choice and there is nothing wrong with tap water for one night. Stop crying like a baby, there was nothing wrong with what you had. What was wrong with no climate control.....what do you at home, do you not turn your thermostat down to 60 degrees at night or do you keep yours at 70 and above all the time??????

Re: Adventure in La La's Land

Post by avi123 on Sat Feb 11, 2012 11:05 pm

archangle wrote:Didn't we have this conversation just the other day?



What conversation?

My original post was on a very important subject that most Sleep Clinics are NOT accredited as such. But you find out about it only after you go there.

Last week I ended up in a Sleep Clinic run by one of the most respected Neurological Center in my area but did not have all rooms with Climate control thermostat in each room. My room which was located at the end of a hall, had temperature of below 70 F and no thermostat. Also, none of the Slimline humidifiers hoses had any insulation on them, not to speak about Climate Controlled lines. In addition, they use faucet water in their humidifiers instead of distilled water. So I could not fall asleep and left by 2:30 a.m. If they dare charging me for the test I will report to Medicare about the crappy situation there, and let's see what happens.

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