How accurate was your sleep study?

I'm curious about those of you who have gotten your titration from a sleep study and have followed it up with an auto and software to see how accurate your rx was.

My first sleep study titrated me at 20cm pressure, but using an Autopap and Encore Pro software, I find that I am only in the 8 - 9 cm pressure for 90%.

Have any of you other software users had such an experience where your sleep study titration was different than what you really needed?

Or how many of you found your sleep study titration to be 'right on' with your software results?

Your answers could prove to be interesting.

SnoreNoMore2005

I'm not sure how accurate my study was as today is the 1st day that I've been able to download my data. My titration study said I had an AHI of zero at a pressure of 9. Well, I wasn't feeling any better at 9 so I bumped my pressure up to 10 (a few weeks ago). In looking at this past weeks data, I found that my avg. AHI (at a pressure of 10 ) is 2.9. Now, why would my AHI increase if I increased the pressure? Who knows....
Amy

My first sleep study resulted in an AHI of 15.9 events/hour, mostly hypopneas with two obstructive apneas. The second study (with an ill-fitting mask, of course ) was tried at 5, 6, 7 and 8 cm, resulting in an overall AHI of 22.1, including 26 central apneas (huh?). Sure sounds a lot worse WITH CPAP! From this they concluded a pressure could not be found, and that I should go on straight CPAP treatment at 8 cm for lack of a better guess.

I decided to go on APAP treatment which has turned out to be a consistent 10 cm using the AutoSpirit.

I think that before you move into a who's right and who's wrong conclusion, keep in mind that during the scoring of the PSG, a hypopnea must not only meet a flow requirement, but has to be associated with an arousal and/or an oxygen desaturation. This is what gives the hypopnea clinical significance. APAP only tracks flow, so that's kind of an unfair advantage. Now, there's good and bad to everything, In the case where the 8 cmH2O was inconclusive, and the APAP said "10 cmH2O is conclusive", that's great, especially if you can attach at least some subjective evidence to that, like "I feel better, I'm less sleepy, I have no desaturations, etc.".
In the case where the PSG titration said 20 cmH2O, but the APAP said 8-9 cmH2O, aren't you the least bit curious as to what they were looking at when they raised the pressure to 20?
You can hold their feet to the fire, have them boot up the PSG and show you the events so you can see for yourself.
The only way to verify that APAP is doing what it's supposed to is to track EEG and oxygen saturation. Other than that, you can press the IFL1's and 2's all day long, till you get a "good" number, but when all is said and done, that's all you've got-- a "good" number.
When you get to the subtleties of the pressure titration, just be aware that the PSG tech is watching for desaturations and arousals, and the APAP is looking for waveform changes. But hey, if you both get to same place, cool. If you don't, shouldn't you at least ask where you are?
deltadave

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CPAPopedia Keywords Contained In This Post (Click For Definition): Titration, Arousal, Hypopnea, APAP

With respect to my "inconclusive" titration, I believe the professional approach would have been to label that night's study as incomplete and repeat it another time using a more complete range of pressures with better data. Taking a stab at a number does not leave me feeling at all confident, and since the sleep doctor is not available for patient consultation (only reads electronic study results ), I am unable to get clarification. And yes, it would be good to know what and why.

In the case where the PSG titration said 20 cmH2O, but the APAP said 8-9 cmH2O, aren't you the least bit curious as to what they were looking at when they raised the pressure to 20?

I'd sure be very curious about that, dave.

SnoreNoMore, do you have any reports from the titration that took you up to 20?

In an older topic, SNM, you had written, "I have had dealings with two sleep docs who are both certified in sleep medicine and members of the doctor sleep medicine societies, etc. Also with four respiratory therapists who work for DME's that provide CPAP's and help with CPAP."

And in another topic, this: "I had an appointment with my sleep doc today and he reviewed my Encore Pro reports."

Did you discuss the discrepancy with that doctor or any of the others? If so, what did they say?

Yeah, I'm very curious about such a huge difference... and just plain nosy.

I know you've written before that you felt a dramatic improvement when you switched from cpap at 14 to autopap, SNM. Still doing well, I hope.

hey fnorette:
Yeah, I do agree that that was a very poor approach by the physician. I would have insisted on a freebie retest. It still may be interesting to get the titration results table, and see how far off they were. It looks like this:

Most reports have something like this in there, in the long report not the summary. Then even if you do end up with an APAP, you have some confidence in the pressures you can work with. And get a better idea what you do in REM, different positions (that's in another table) and the like. There's important information to be gained from the PSG, and I'm saying take advantage of it when its there, and insist upon it if you feel you've been short-changed. Then you can have the confidence that your therapy is appropriate.
Also SNM, if you can get a hold of this table, it might have some interesting data in re: what happened at 20 cmH2O.
deltadave

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CPAPopedia Keywords Contained In This Post (Click For Definition): Titration, APAP

Thanks for posting that table, dave.

What exactly should a person ask for copies of, when going to the doctor for the follow up appointment:

1. after the PSG diagnostic study

2. after the PSG titration study

What are the actual names of the reports a person should ask for, so there will be no confusion if the person is interested in receiving as much information as possible about what went on during the study/titration?

IJust completed a retitration study last night. The first since1999, but I haven't used CPAP consistently since 2001. This time I was only permitted to sleep on my back the entire night--is that normal? The first study I had let me move around at will--no restrictions.

Hey RG!
As luck would have it, got one right here.
The report is pretty standard, and should have:
Sleep Architecture including onset and efficiency
Sleep Stages, REM and NREM
Respiratory Analysis, including apneas and hypopneas, incidence in REM and NREM and relation to body position.
PLMs
Arousals for respiratory events, PLMS and spontaneous arousals
Desaturations, total and lowest
Graphs of Architecture, Oxygen Saturation, Respiratory Events and Body Position (usually it's all on one page)
For CPAP/BiPAP titrations, that table will be fine.
Raw numbers (total for the night) and indexes (number per hour) wherever possible.
Ask for the Complete Report, not the Summary.
deltadave

My titration appears to have been "spot on".

It probably helps that:

a) I was the only patient in the sleep lab that night;
b) the RT was a 20 year vet;
c) the RT also has OSA so he understands what I was going through;
d) the RT and I hit it off and spent quite a bit of time chatting before starting so we would understand each other and so I'd have a very clear and detailed understanding of what was about to happen.

This certainly seems to have been unusual, based on other's experiences.

My sleep study listed the baseline results (57.6 AHI) and therapeutic results (11.2 AHI) with an optimal pressure of 20cm/water but did not give a description of the therapeutic results at each pressure setting. It did say with treatment, my RDI dropped to 0.0 which sounds a bit contradictory to 11.2 AHI therapeutic results.

I do remember Nurse Ratchet telling me that she "had turned the CPAP all the way up and it still wasn't working". The whole study, including the facility and the staff had a bad smell to it if you know what I mean.

For more detailed information, see my Sleep Study Nightmare at:

viewtopic.php?t=4210&highlight=

DeltaDave, your advise is good assuming I wanted to waste my time demanding Sleep Sawbones #1, whom I had never met, explain why my sleep test results were off the charts. IMHO a doc will attempt to defend his/her and their staff's malfeasance regardless of the diagnosis. Instead, I simply got a new sleep doc who reviewed Sawbones #1 report and said I should have another sleep study at a different sleep center to validate or invalidate my first study's results. That made a lot of sense to me.

But for my second sleep study I was so anxious, (like a dog who had been whipped) I couldn't even fall asleep so there was no titration result. This is why sleep doc #2 recommended the Autopap. (Thank God)

The bottom line is if I would have just followed doctor's orders from Sleep Study #1 like so many people do, I would have been sent home with a CPAP preset to 20cm. I wonder how long it would have taken me to become one of the non-compliant statistics who would have continued to suffer from OSA?

RG, thanks to you and others, I'm doing really well on the Autopap. I run two miles and swim laps in the morning before breakfast. Maybe that's no so phenominal except 3 - 4 months ago I was feeling like hell dragging myself out of bed, dragging myself through the work day, and dragging myself home after work depressed, fatigued, and anxious.

I feel like thanks to an APAP and some very sound advise from people in this forum, I have my life back. For that I am grateful beyond words.

SnoreNoMore2005

Thanks for the list, Dave!

If ever..... heheh ... I'll know what to ask for afterwards.

SnoreNoMore, I think you're probably right about what you'd have heard if you'd tried to get an explanation from Sawbones #1, as you call him. After all, he's the one who prescribed 20 after he saw the report. He'd be defending himself as well as defending Nurse Ratched's exquisite titration technique, such as it was.

More than likely, he just went through a stack of reports on his desk, glancing at the bottom line pressure and signing Rx's left and right. You did well to escape to another doctor. And to the message board.

You're right about how most people would simple accept what that first doctor recommended, try to endure an unendurable treatment.... and quietly quit.

Sad situation.

1st Sleep Study (Major hospital in Miami, FL) - New sleep lab temporarily set up in their cancer ward. The only technician happened to mention that the last technician was fired for leaving his post and going out with his girlfriend. Leaving the patients sleeping by themselves in the otherwise empty cancer ward with the door unlocked. Needless to say I slept REAL good through that study which found I had NO apnea.

2nd Sleep Study (Major hospital near Key Biscayne, FL) - New Sleep Lab again. Kept raising the pressure up so high all night that I couldn't even force my lips shut. Never offered water, or FF mask (I didn't know about FF masks back then). 20 minutes before the study ended I refused to continue. They reported no Apnea and that I refused to finish the study.

3rd Sleep Study (Same major hospital in Miami as first study) - Same results no apnea, still a bunch of rookies there.

4th Sleep Study (I'll mention the name of this hospital. Broward General Hospital in Broward county Florida). Very professional from start to finish, in a "home" type environment to relax the patient. Lots of communication before, during, and after the study. They recommended a fixed pressure of 16. I was given a really noisy and cheap machine by the equipment company so I always kind of doubted the pressure setting. (more later on this)

5th study (Brand new hospital/clinic in West Fort Lauderdale, FL): Again very professional, relaxing atmosphere with good communication. They recommended a pressure of 11, and I convinced them to prescribe a RemStar Pro Auto-CPAP and bought the software to go with it here at CPAP.COM.

After several months of tweaking the Auto pap hovers at an average of 15.8, so the 4th study seems the most accurate.

If you're uncomfortable with your machine and/or don't feel confident about the sleep lab - KEEP ASKING FOR MORE TESTS! You WILL feel better, I do!

The discomfort I felt after the 4th study was due to the cheap machine the DME provided (noisy, no C-FLEX, and found out the pressure drifted way up on it), but the prescribed pressure by the lab seems right on the money.

Hi Guys!
SNM, in re: your results:

My sleep study listed the baseline results (57.6 AHI) and therapeutic results (11.2 AHI) with an optimal pressure of 20cm/water but did not give a description of the therapeutic results at each pressure setting. It did say with treatment, my RDI dropped to 0.0 which sounds a bit contradictory to 11.2 AHI therapeutic results.

The 11.2 AHI was undoubtedly the summary of all pressures tried during the night, whereas the RDI 0.0 was the observed pressure at the "ideal" setting [deltadave ducks flying object] hey, I'm just explaining what it is.

There's really two separate questions here. The first is, can PSG, if done properly, offer important, even critical information in the diagnosis and treatment of sleep disorders? The answer is absolutely and unequivocally, yes.
The other question is, are there people out there performing and interpreting sleep studies that are money-grubbing, incompetent, uncaring idiots? The answer again is absolutely and unequivocally, yes.
As a member of the field, I find it personally embarrassing to hear these stories. I think that's true of anybody in any field who takes pride in their work-- "do not ask for whom the bell tolls..."
One of the causes is that the field of sleep has expanded so rapidly that there are few safeguards to control it. Not none, few. But I think instead of running a poll asking who was right, the APAP or the PSG, it would be far more beneficial to ask for people who dealt with problems and won. Because labs and physicians have valuable information that you need, that you paid for, and we should all have a responsibility to prevent the injustice that happened to you from happening to other people.
I'll start:
Overall, try to stay with sleep labs that are accredited by the AASM or are within or sponsored by hospitals. There will be more avenues of recourse.
When you have a problem of the nature that SNM described, write directly to the President or CEO of the hospital. Almost all hospitals have an effective system in place to handle to patient complaints. This also uses that money-grubbing philosophy against them. A lot of complaints means a potential loss of revenue, so in many cases, that'll get 'em moving.
Write directly to the Risk Management Department of the hospital. They investigate all issues where potential harm exists, and people really listen to this group.
If the laboratory that gives you a problem is accredited, drop the AASM a line at http://www.aasmnet.org/.
The organization for the Board Certified sleep physicians is http://www.absm.org/.
While I don't think these two organizations may be equipped to handle complaints, if they start to get a lot of 'em, then maybe they'll consider it's an area that they should get into. Like everything else, it's about supply and demand. And these organizations would absolutely want to know if there's somebody out there performing poorly and using their seal of approval, it doesn't do them any good either.
The goal of all these things is to not necessarily get a pound of flesh, which I'm sure at this point, you feel you need and probably deserve, but to get those people who are performing poorly to think twice about poor performance, rudeness, and a lack of sympathy. It's a big problem, a big rock, but if everybody takes a chip out as they walk by, it'll eventually get busted up.
deltadave

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CPAPopedia Keywords Contained In This Post (Click For Definition): AHI, RDI, seal, APAP