Need some help (data review)

Thanks for the link. I don't mind jumping through the hoops but I do mind the $$$$ that they require. My insurance is paid up this year until Dec 1, 2011. Until then insurance will pay 100% because I have already paid out of pocket max. After that date I will be required to pay another $4,500 before insurance pays.

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justbreathe, how do you feel with the lower pressure? I wonder if such a small drop would make much difference. But overall do you experience any of the following (besides PLM):

Like obstructive sleep apnea, central sleep apnea frequently presents with nighttime awakenings, nocturnal hypoxia, and excessive daytime sleepiness.[14] Sometimes, bed partners report witnessed apneas and mild snoring. Patients also report nonrestorative sleep, choking, and shortness of breath.

The most common reported symptoms are insomnia and excessive daytime sleepiness or fatigue. In general, the degree of daytime hypersomnolence is less than that observed with obstructive sleep apnea, and insomnia is more prominent. The presence of insomnia may actually put these patients at increased risk of central apneas because a greater number of sleep-wake transitions provide more opportunities for an unstable breathing pattern.

Patients also may have symptoms pertaining to the underlying cause (eg, symptoms of heart failure, stroke, renal failure, Parkinson disease, or multiple system atrophy). Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and other heart failure symptoms can be seen with CSB-CSA.

RT came by and changed pressure to 6. I could not wit to check it out so I took a nap for 45 minutes with no events registered. We will see how tonight goes?

I've been following your various threads. ozij's posts above pretty much sum up most of my thoughts. Your centrals went up with the pressure. That may (or may not) go away with time. Your now-lowered pressure may leave you with residual hypopneas (this would be suggested by the data, albeit limited, from your titration study).

Don't underestimate the impact of the PLMD on your sleep and breathing, or the confounding impact it can have on data analysis. As kteague and I will both attest, it's quite frustrating.

Like Pugsy said and ozij echoed, this is going to require some serious time and discussion with your doctor. An ASV is not necessarily going to be a magic bullet here (despite it sometimes being billed as such).

My personal opinion, having gone through four sleep studies in the past 14 months or so, and battling three of the same things you are (obstructive apnea, treatment-emergent centrals, and PLMD), would be that if you have another titration, try an approach to treat the PLMD first. I went about it the other way around and, personally, wish I hadn't. There are pros and cons either way.

I had blood work to check for iron and everything else that could be causing the PLMD. All labs came back as normal. I am curious to see how the lower pressure effects my results. It would be so nice to lay down and not wake till the morning.

I don't want to start taking nasty drugs for this.

justbreathe wrote:I had blood work to check for iron and everything else that could be causing the PLMD. All labs came back as normal. I am curious to see how the lower pressure effects my results. It would be so nice to lay down and not wake till the morning.

I don't want to start taking nasty drugs for this.

I'm in the same boat. My bloodwork has back several times with flying colors too. And like you, I'm already on Lisinopril-HCTZ and various other things. And like you, I'm an otherwise health, not-obese male whose diagnostic consisted almost entirely of hypopneas.

A year lapsed between my diagnostic sleep study and my fourth study (an ASV titration) when I started trying the meds -- Mirapex ER, and then Requip. I hope you are more fortunate than I am. The reason for my original advice about tackling the PLMD side first is as follows: I still don't feel great or refreshed on my ASV + Requip combo. And because there's nothing left to "titrate" me on, I have no way of knowing whether the meds have made any difference or not. Which leaves the question open for me as to whether my continued fatigue can be attributed to PLMD that is not responding to medication, or to something else. That's the only reason I brought it up.

It *is* a chicken and egg game sometimes, and A can affect B, or B can affect A. So I don't know that there's a "right" answer.

BrianinTN wrote:

justbreathe wrote:I had blood work to check for iron and everything else that could be causing the PLMD. All labs came back as normal. I am curious to see how the lower pressure effects my results. It would be so nice to lay down and not wake till the morning.

I don't want to start taking nasty drugs for this.

I'm in the same boat. My bloodwork has back several times with flying colors too. And like you, I'm already on Lisinopril-HCTZ and various other things. And like you, I'm an otherwise health, not-obese male whose diagnostic consisted almost entirely of hypopneas.

A year lapsed between my diagnostic sleep study and my fourth study (an ASV titration) when I started trying the meds -- Mirapex ER, and then Requip. I hope you are more fortunate than I am. The reason for my original advice about tackling the PLMD side first is as follows: I still don't feel great or refreshed on my ASV + Requip combo. And because there's nothing left to "titrate" me on, I have no way of knowing whether the meds have made any difference or not. Which leaves the question open for me as to whether my continued fatigue can be attributed to PLMD that is not responding to medication, or to something else. That's the only reason I brought it up.

It *is* a chicken and egg game sometimes, and A can affect B, or B can affect A. So I don't know that there's a "right" answer.

Brian might be right that this case could be plain PLMD and/or RSL disorders [my addition: and nothing to do with Obstructive Sleep Apnea Syndrome, in which case a CPAP or ASV would not help.]

Check a similar case here:

http://www.med.ucla.edu/modules/wfsecti ... icleid=324

See also:

http://www.mayoclinic.com/health/restle ... -and-drugs

Last night:

Mask on: 8:53
EPR: 3
Pressure 6
Obstructive Apnea 0.6
Central Apnea 7.6
Hypopnea Index 0.1
AHI 8.4
Median Leak 0
95% 1.2
Maximum Leak 26.4
Climate 82

I did wake about 2:30 and look at my cpap the reading at that time was AHI 4.9. I rolled from my back to my right side and slept the rest of the night. My second half of the night was much worse with many centrals. I assume due to PLM and I did notice more difficulty with congestion when laying on my side. Eventually I just went back to laying on my back where I have less congestion.

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justbreathe wrote:Last night:

Mask on: 8:53
EPR: 3
Pressure 6
Obstructive Apnea 0.6
Central Apnea 7.6
Hypopnea Index 0.1
AHI 8.4
Median Leak 0
95% 1.2
Maximum Leak 26.4
Climate 82

I did wake about 2:30 and look at my cpap the reading at that time was AHI 4.9. I rolled from my back to my right side and slept the rest of the night. My second half of the night was much worse with many centrals. I assume due to PLM and I did notice more difficulty with congestion when laying on my side. Eventually I just went back to laying on my back where I have less congestion.

Reply:

In my opinion you need to resolve the issues of the hi % of CAI in the AHI, the PLMD, and the Positional. Have you noticed that your Sleep Study "Impression" is directed to a DOCTOR. What type of MD do you have? I would take all the papers and go see a Neurologist MD ASAP. You got over there MDs graduates of the UNC system.

My General Practice MD sent me to a Lung Specialist who sent me to sleep test. Sleep Dr. who I never saw read sleep study.

Then I went back to my GP for blood tests. I have a Sept. Appointment with lung DR. to discuss sleep study.

Should I bypass pulmonologist and go to neurologist?

justbreathe wrote:My General Practice MD sent me to a Lung Specialist who sent me to sleep test. Sleep Dr. who I never saw read sleep study.

Then I went back to my GP for blood tests. I have a Sept. Appointment with lung DR. to discuss sleep study.

Should I bypass pulmonologist and go to neurologist?

No, I would keep the appointment with the pulmonologist (I assume an MD).

Actually, my present "Sleep Doctor" has the following designations:

INTERNAL MEDICINE & PULMONARY MEDICINE

Board certified: Internal Medicine, Sleep Medicine, and Pulmonary Diseases


He belongs to a group of internal medicine "consultants" who are not Medicare or BCBS of NC providers.

They also "run" a "sister" company of a sleep study clinic.

For personal visits I need to pay some 20% extra (over Medicare) from my pockets but not for labs or the sleep clinic.

They are good. But at any moment if I change my mind, I could switch to another group that is fully Medicare and BCBS provider and the doctors there are mostly UNC-Carolina or Duke graduates.

Overall, for the PLMD, since it has to do with brain arousal and awakening, I would seek the help of a neurologist. For the central apnea I would also try to be checked by a cardiologist. Central apnea could be caused by any of multiple underlying medical conditions. So you may need to go from one specialist to another.

justbreathe wrote: Should I bypass pulmonologist and go to neurologist?

I have two personal opinions here:
1) More medical advice is a good thing, so as long as it doesn't seem "wasteful" and is affordable given your personal health budget
2) Some doctors are more attentive and simply better than others, and education is a poor proxy for that

I would focus your money and your energy on the doctor that shows willingness to look at your data and think about your situation. The one with their hand on the doorknob -- run, don't walk.

Just received a call from Dr. They are sending me back for titration on ASV.