Wit's End Sleep Data

At the suggestion of echo, I've gathered some data, including my last PSG which I picked up from the sleep doc today. Having actually never seen one before, I was a bit shocked at what they didn't tell me, not to mention a bit puzzled as well. The cover page recommendation says '...use humidified [smudge]PAP with compliance set at 7 cm H20..." There was a smudge on the copy right in front of 'PAP', so I don't know if it was a C or A, but I would assume 'C'. Here's the puzzling part...they told the DME to set the machine on Auto with a 9-12 range, which is where it still is. <sigh>

Here's some data from the last few nights courtesy of ResScan
Pressure::AI::AHI::Leak
11.2 :: 2.1 :: 9.4 :: 0
11.8 :: 3.0 :: 10.3 :: 3.6
11.0 :: 2.4 :: 8.5 :: 0
10.6 :: 0.7 :: 5.7 :: 0
11.0 :: 1.9 :: 6.3 :: 0
10.2 :: 2.7 :: 7.0 :: 0
11.2 :: 1.2 :: 5.1 :: 0
10.8 :: 1.7 :: 7.4 :: 0
10.8 :: 0.7 :: 6.1 :: 0
10.8 :: 3.3 :: 8.8 :: 6
11.0 :: 2.1 :: 6.5 :: 0
11.0 :: 1.1 :: 6.0 :: 0

Generally, I have nasal congestion issues from dust mites/mold alergies. As of last week my ENT has given me a combination of Nasonex and Astelin, which has started to help keep things open, and sleeping on my left side seems to help with that as well.

All that said, the machine numbers tell the doc "it's working!", but I feel horrible in the AM...the feeling of a never-ending all-nighter. I am getting awake about once every hour for some reason. Sometimes I do know the reason, dry itchy nose, for example. But I think that most times its something with the therapy. Dreams come briefly.

The PSG is full of stats I have no idea how to interpret. Maybe there's a clue in there, but I'm not likely to find it without help. They seemed to be satisfied with a total events (AI + HI) of 4.2 and a SaO2 range of 90-97%

Where do I go from here?

For starts, I would get a clarification of the Machine prescribed. I was prescribed a CPAP initially and was on it for a month.
I knew from my titration that something wasn't right. I didn't feel as well as I did from that sleep study.

So, I talked to my Sleep Doc, told him something wasn't right. Good Thing!! The Sleep Tech found BiPap to be the optimal prescription during the Sleep Study.

Many Insurance Companies will require CPAP first to see if it works well enough for the patient. If not, the BiPap is prescribed if the Sleep Study found it to be the right choice. It's all about saving money!


Take care,

SG

You do not keep anything for a special occasion, because every day that you live is a special occasion.
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Sleepdep, seems to me that the AHI is a bit high, even if the AI is low. Have you determined whether you were prescribed a CPAP or APAP?

Some people sleep better with straight CPAP than with APAP - that is possibly why you keep waking up.

That is bizarre that they titrated you at 7 (though I don't know what "compliance set a 7" means... what a weird phrasing!), but you're on 9-12 APAP. On the other hand you seem to be at around 11 most nights (Is that your 90% pressure or 95% or ...?).

You might want to try a straight CPAP at 11 and see how that works, as I said maybe the APAP mode is waking you up. Try it for a week and see how you feel , and how the numbers go. That's just my non-medical "advice".

sleepdep wrote:The PSG is full of stats I have no idea how to interpret. Maybe there's a clue in there, but I'm not likely to find it without help. They seemed to be satisfied with a total events (AI + HI) of 4.2 and a SaO2 range of 90-97%

I'm confused now - was the PSG from the study with or without the CPAP? I'm assuming that's your titration report-- because if you had an AHI of 4.2 during the PSG but with the APAP your AHI is now more than double... well it just doesn't make sense. You can always scan in your PSG and post it online (or PM/email it to one of us) and we can help you interpret it (black out personal data).

sleepdep wrote:At the suggestion of echo, I've gathered some data, including my last PSG which I picked up from the sleep doc today. Having actually never seen one before, I was a bit shocked at what they didn't tell me, not to mention a bit puzzled as well. The cover page recommendation says '...use humidified [smudge]PAP with compliance set at 7 cm H20..." There was a smudge on the copy right in front of 'PAP', so I don't know if it was a C or A, but I would assume 'C'. Here's the puzzling part...they told the DME to set the machine on Auto with a 9-12 range, which is where it still is. <sigh>

Here's some data from the last few nights courtesy of ResScan
Pressure::AI::AHI::Leak
11.2 :: 2.1 :: 9.4 :: 0
11.8 :: 3.0 :: 10.3 :: 3.6
11.0 :: 2.4 :: 8.5 :: 0
10.6 :: 0.7 :: 5.7 :: 0
11.0 :: 1.9 :: 6.3 :: 0
10.2 :: 2.7 :: 7.0 :: 0
11.2 :: 1.2 :: 5.1 :: 0
10.8 :: 1.7 :: 7.4 :: 0
10.8 :: 0.7 :: 6.1 :: 0
10.8 :: 3.3 :: 8.8 :: 6
11.0 :: 2.1 :: 6.5 :: 0
11.0 :: 1.1 :: 6.0 :: 0

Generally, I have nasal congestion issues from dust mites/mold alergies. As of last week my ENT has given me a combination of Nasonex and Astelin, which has started to help keep things open, and sleeping on my left side seems to help with that as well.

All that said, the machine numbers tell the doc "it's working!", but I feel horrible in the AM...the feeling of a never-ending all-nighter. I am getting awake about once every hour for some reason. Sometimes I do know the reason, dry itchy nose, for example. But I think that most times its something with the therapy. Dreams come briefly.

The PSG is full of stats I have no idea how to interpret. Maybe there's a clue in there, but I'm not likely to find it without help. They seemed to be satisfied with a total events (AI + HI) of 4.2 and a SaO2 range of 90-97%

Where do I go from here?

Your best AHI was obtained at pressure 10.6 to 10.8. But you still feel bad?

That bad feeling may or maynot be associated with OSA, but let's assume it is. Your AHI shown above is NOT the cause of that fatigue, what is puzzling here is how the Sleep Lab missed your pressure by 3 cm or more, that is IF they did. Could very well be a reason they established 7 cm as your pressure, as going higher your sleep architecture falls apart so they backed-off of the higher pressure and resorted to a pressure of 7 cm that produced better sleep.

Now the modern day autopap is pretty good at finding your 90-95% pressure it doesn't have an EEG and ECG data to make its determination, it only goes by the flow it sees, if it doesn't see any flow it assumes it is from an apnea and it increase pressure, if it sees the vibrations from snore it increases pressure. But it cannot see an EEG/ECG brain wave data.

So my suggestion:

1. Press the center down button and the right button at the same time, hold for 3 -5 seconds, go to clinical menu and
lower the Minimum pressure from 9 to 7 or what your PSG showed. Press the On/Off button to exit or let it time out.

2. Observe how you feel with the new lower pressure, if you feel better than last night assume you may have an intolerance
to higher pressure. Observe AHI more specifically AI, compare to the data you have above. You can EXPECT it to go a bit
higher but your goal is to FEEL better.

On the opposite end of the scale, you may assume your pressure is not high enough. This could easily happen as well, if those
events that are leaving you feeling fatigued are apnea. Because once you are over 10 cm pressure, that machine will NOT respond
to any apnea seen. At or above that pressure it only responds to Flow Limitation and Snore. You would have to go over your
PSG to see what type of events are seen during your sleep, if they are mainly apnea and few hypopnea then machine is not going
to respond accordingly.

3. If lower pressure doesn't make you feel better, try higher pressure than shown above, machine says your 95% pressure where AHI
is ideal is 10.6 to 10.8 range resulting in lowest AHI. Machine is going to stop at 10 cm on Apnea, what if you are having apnea above that pressure? It will let them go by untreated. So you have to manually take care of those, you do that by increasing the Minimum pressure, in your case you would move the Minimum up from current 9.0 to 10.8 or 11. New range effectively becomes 11 to 15.
So you try a higher pressure and again observe the AHI or AI, if it doesn't increase the AHI you have gone the right direction.

But in the end it is the settings that allow you to feel better is what you are after, feeling better always takes presidence over AHI or
pressure used. I prefer to eliminate the lower pressure range first, because if you start off too high you can totally miss your
sweet spot when it comes to pressure.

Was there any notation on the PSG for CA (Central Apnea) or MA (Mixed Apnea)? Any microarousals or spontaneous arousals mentioned?
What was your oxygen levels dropping to? What about your sleep architecture? Did these return to normal under 7 cm pressure?

Stuff seen on a PSG:
DEFINITIONS:
APNEA = cessation of airflow for 10 seconds or greater.
HYPOPNEA =>50% decrease in airflow for 10 seconds or greater with a decrease in oxygen saturation of >3%.
APNEA/HYPOPNEA INDEX (AHI) = apnea plus (+) HYPOPNEA/hour of sleep.
RESPIRATORY AROUSAL INDEX (RAI) = AHI +snoring related EEG arousals/hour of sleep.
AHI/RAI** Scale =<5 events /hour = (none); 5-15 events/hour = (mild); 15-30 events/hour = (moderate); >30 events/hour = (severe).
Respiratory related sleep fragmentation: Sleep arousals due to respiratory events or snoring.
Desaturation = Drop in O2 oximetry distribution saturation by 3% below average saturation.
SaO2 scale: >89%=(none); 85-89%=(mild);80-84%=(moderate); <80% (severe).
EPWORTH SLEEPINESS SCALE =<10=(does not indicate EDS (Excessive Daytime Somnolence));10-15=(indicates daytime somnolence-not excessive);>16 (indicates EDS).
RESPIRATORY EFFORT RELATED AROUSALS (RERAs)=Sleep Arousals due to respiratory events characterized by pressure flow limitations in the airflow indicator channel without significant O2 desaturations.
StageIII and StageIV are combined and referred to as Deep Sleep.
Sleep Efficiency = Normal is >80%
As established by AASM/ABSM 1999.

Normal Sleep Architecture:
Stage1: 5%
Stage2: 50%
Stage3: 10%
Stage4: 10%
Stage REM: 25%

Stage3&4, REM decrease as we age.


Stuff seen on a PSG Report:

Arousal: An interruption of sleep lasting greater than 3 seconds.

BR Arousal index: The number of breathing related arousals(apnea, hypopnea, snoring & RERAs)multiplied by the # hours of sleep.

Bruxism: Grinding of the teeth.

Central apnea: A respiratory episode where there is no airflow and no effort to breathe lasting greater than 10 seconds.

EEG/EOG: Comments about sleep stages, brain waves (EEG), or eye movements (EOG)

EKG/ECG: Comments about heart rate, abnormal heart beats, etc.

EMG: Comments about leg movements and or teeth grinding (bruxism).

Hypopnea: A respiratory episode where there is partial obstruction of the airway lasting greater than 10 seconds. Also called partial apnea or hypo-apnea.

Non-supine: Sleeping in any position other than on the back.

NSR: Normal sinus rhythm.

NPSG: Nocturnal Polysomnogram, or sleep study.

(#)Number of Awakenings: The number of pages scored as wake after sleep onset.

Obstructive apnea: A respiratory episode where there is a complete cessation of airflow lasting greater than 10 seconds.
PLMs: Periodic limb movements.

PLM arousal index: The number of periodic limb movements that cause arousals multiplied by the number of hours of sleep.

PSGT: Polysomnographic technologist.

REM latency: Latency to REM(dreaming) from sleep onset.

RERAs: Respiratory effort related arousals. Episodes that are not apneas or hypopneas, often related to loud snoring, that generally do not cause a decrease in oxygen saturation.

Respiratory: Any specific comments about respiratory events.

RPSGT: Registered polysomnographic technologist.

Sleep efficiency: Total sleep time multiplied by time in bed.

Sleep latency: The first 30 seconds (one `epoch' of recording time) of sleep.

Sleep onset: The first 90 seconds (3 `epochs) of uninterrupted sleep.

Sleep stage shifts: The number of incidents of sleep stage changes.

Snoring intensity: Level of snoring loudness determined by the sleep technologist. Ranging in degrees from mild to very loud snoring.

Spontaneous arousal index: The number of spontaneous arousals (e.g. arousals not related to respiratory events, limb movements, snoring, etc) multiplied by the number of hours of sleep.

Stage 1: The lightest stage of sleep. Transitional stage from wake. top

Stage 1 shifts: The number of times the sleep stage changed to stage 1.

Stage 2: The first true stage of sleep.

Stages 3/4: The deepest, most restorative sleep.

Stage REM: The dreaming stage; Normally occurs every 60-90 minutes.

Supine: Sleeping on back.

Time in bed: The time in the study from `Lights Out' to `Lights On'.

Total arousal index: Total number of all arousals multiplied by the number of hours of sleep.

Total # of PLMs: The number of leg movements in sleep that last greater than 0.5 seconds.

Total sleep time: Total time asleep.

WASO: Wakefulness after sleep onset.

WNL: Within normal limits.