Please HELP me with statistics

[sleepytexan]

Hi jules. Thanks for the response.

If you were titrated at 15 why did you up the pressure?

Actually I had 20 days of data before what I have posted. The Dr. took a look at them and then prescribed that I go up to 17. It made a good difference so I up'ed it to 18. It does not really look like from 17 to 18 made much of a difference except it sure is hard to get the mask on without leaking. Maybe I need a new doctor?

Your leak graphs aren't good enough imho to start changing pressure based on what your encore pro reports show. Get the leaks under control and then look at the events.

I use the Mac's silicone earplugs and get the best fit with that. Any other suggestions? I have tried about 15 (yes, no kidding, 15) masks at the supplier and what I have now was the best fit.

Also in your report from the lab was there any discussion of centrals?

I do not have my report yet. I am in the process of having the doctor fax it over.

Thanks again,
Doug

[rested gal]

I have posted the nightly report from Encore Pro for 10 nights here:
http://www.iamtexan.us/nightly2.pdf

Thanks...THAT's the kind of report that gives the best picture of what's happening...those "Daily Details" graphs from Encore Pro (exactly the same kind of graph that Encore Viewer produces.)

I do not know what being titrated at means and I do not have the actual report but if it means the original pressure recommendation, it was 15.

Yes, that's what "titrated at" means... it's the pressure the sleep tech found to treat you well during the titration night when they put a cpap mask on you and started manually adjusting the pressure while they watched what each pressure did to correct your sleep disordered breathing at the sleep lab. The pressure the sleep tech came up with is usually the pressure the doctor prescribes. In your case, a pressure of 15 from the sleep study titration.

What did the sleep study report say was your total AHI (it might have been called "RDI" on the report) at a pressure of 15?

Sorry for all of my ignorance. This is all starting to mean something to me but it has been very slow

No need to apologize, Doug. You're doing a great job providing the downloaded info from your machine and working on your treatment. It takes awhile to figure out what data to look at, or what to provide others to look at. You're determined, pro-active about your own treatment, and you're continuing to dig into this message board to find help. That's what matters.

Those extreme numbers of obstructive apneas on all your Daily Details reports are making me think of three things...any one of which, or combo of them, might be at play. But I'm not a doctor!

1. Single pressure set too low, as ozij mentioned.

2. GERD interfering with cpap's ability to push throat tissue aside. Have you ever been diagnosed with GERD? Acid reflux disease. If so, are you agressively being treated for GERD?
Nov 05, 2005 subject: SUCCESS AT LAST-GERD,420E, PRILOSEC AND BENADRYL -SWS's thoughts on loonlvr's massive clusters of events and loonlvr's followup post.
viewtopic.php?t=5551

3. CompSAS (also called CSDB) Complex Sleep Apnea Syndrome/Complex Sleep Disordered Breathing -- a hallmark of this is that more apneas show up WITH cpap treatment than without, but the additional apneas are usually central apneas, I think, rather than obstructive. Your machine cannot distinguish centrals from obstructives. (However, my bet is that those really are obstructives.) A better place to look for CompSAS is in the full reports from the PSG, especially for the titration night. If a person has CompSAS, there are highly specialized machines -- Respironics' BiPAP Auto SV and ResMed's VPAP SV -- that are much better at treating that sleep breathing disorder than the usual machines. But don't go worrying down that path at this point. Possibilities 1 and/or 2 are very likely what could be responsible for your high AHI despite "some" treatment, and should be ruled out first, imho.

Good luck, Doug. You're gonna get to "good" treatment fine. You're working diligently on it, and you're sure to get plenty of encouragement here.

[twocents]

It starts making sense after a while.
I am starting to understand the reports a bit better.

[sleepytexan]

Okay, so I just received my original sleep test results and it says that my RDI (or AHI) at a pressure of 15 was 16.0 with 2 Centrals per hour. There were no Centrals until the pressure of 15 was reached. I thought the goal was to get the AHI down to less than 5? Did they not take the study far enough? This gets more confusing, the more I learn about it. Is this as good as it gets?

[Snoredog]

they blew your titration should have titrated you on bipap.

think I'd find another doctor, lab or both.

[jules]

they blew your titration should have titrated you on bipap.

think I'd find another doctor, lab or both.

yep

something is very fishy - was this a one night study - diagnosis and cpap titration both in one night?

[sleepytexan]

yep

something is very fishy - was this a one night study - diagnosis and cpap titration both in one night?

No actually it was the second night. The first was just a sleep study. I actually slept 6.9 hours at the 2nd night's study, enough time to try two masks.

[jules]

You might want to scan, delete private information such as names, and post the reports. What was your original AHI? Getting 16 afterwards isn't that great. You might need more than a bipap titration. Are there other medical issues?

You might also want to inquire on the board about others experiences in your part of the country - good and bad docs, labs, etc. I don't know how much people might be willing to post or pm you this information if you post a general inquiry such as "looking for a good doc/lab in or near ......... "

[sleepytexan]

Thanks everyone for your feedback. Although it's depressing, I need to know what is going on and will take your suggestions to heart.

[jules]

This forum can handle people with plain old OSA for the most part. We can look at output, make suggestions on leaks, pressures, hand hold, etc. and get a lot of people on the road.

However, if there are more complicating conditions (heart or lung problems for example), then you need to find experts in your area to seek advice from. In this case you were getting centrals at 15 and 15 wasn't enough to get your AHI down low enough. That might be as good as it will get on a straight cpap, but there are fancier machines out there and you have to seek them out; no one is going to offer one to you even as door stop.

You obviously have done the first part by ending up in a sleep lab for 2 nights, however, they weren't able to handle your problems. It might have been the inexperience of a tech at fault or might be the interpreting doc or might be neither of these. What they came up with isn't good enough. You need something else, and got to push it.

It might be that no one can find all the answers. However, you need to go back to your PCP and say you need to find the best sleep doc in the area for now, not just any sleep doc, and if your PCP says that is who you were sent to you need to increase the area of where you will find a sleep doc. Some people end up with sleep docs across country when they have complicating conditions.

[mindy]

Best of luck, SleepyTexan. I know it can be discouraging at times but you've persisted so far so I really hope you will keep it up! It may take some time to get this resolved but I think you have the persistence to do so and it will pay off in the long run.

Take care!
Mindy

[ozij]

At this point, there's no reason to think the titration was "blown".

Some insurance companies will agree to pay for a bi-level machine only after failure on fixed pressure is proved. So you were given fixed pressure at 15 - which left you snoring, and fixed pressure at 17 - which solved snoring and made the AHI better, but far from good enough.

http://www.aasmnet.org/Resources/Practi ... essure.pdf

Bi-level therapy is a guideline recommendation, not a standard.

4.5.1 While the literature mainly supports CPAP therapy, BPAP is an
optional therapy in some cases where high pressure is needed and
the patient experiences difficulty exhaling against a fixed pressure
or coexisting central hypoventilation is present (Guideline).
This recommendation is based on 2 Level I studies81,82 which
yielded no evidence that BPAP improves efficacy or adherence
in the management of OSA compared to CPAP [7.2.2]. APAP is
also a treatment option; however, this was not incorporated in the
accompanying review paper since an earlier review and practice
parameters for APAP was published in 2002.83

I'd go back to the same doc, complaining, showing my results, and discussing a bi-level titration. You might find you doc in full agreement with you, especially after he sees your results.

Since the AHI did drop when the pressure was raised, and the snoring stopped, my non-professional guess is that it's OSA in need of higher pressure.

I think its even possible that your very unsmooth leak rate during those non-stop apnea is actually a result of the machine blowing on with the air having nowhere to go but out - and possible restlessness caused by the apneas. On some of those graphs, when you don't have apnea, the leak may be just as high, but stable.

Fixed pressure doesn't work for you - and make that very very clear to your doctor. You have no reason to stick to the present Rx - but that doesn't mean your doc. should be distrusted. Could he be a bad doctor? Theoretically yes - any one could be. Is he a bad doctor? At this point in time, you have no reason to think so, and if he were my doctor, I would certainly assume he is professional until proven otherwise.

Keep us posted.
O.

[Snoredog]

At this point, there's no reason to think the titration was "blown".

Some insurance companies will agree to pay for a bi-level machine only after failure on fixed pressure is proved. So you were given fixed pressure at 15 - which left you snoring, and fixed pressure at 17 - which solved snoring and made the AHI better, but far from good enough.

http://www.aasmnet.org/Resources/Practi ... essure.pdf

Bi-level therapy is a guideline recommendation, not a standard.


O.

WHO said it was a Standard YOU? sure and the hell wasn't me. 2 studies already how many more do you need? The guy's residual OSA qualifies for Severe OSA treated.

Maybe you need to see a couple more months worth of reports. Guys AHI is all over the place, was given the cheapest CPAP machine on the planet, obviously NOT capable of even remotely resolving his condition, if that doesn't demonstrate lack of experience on his doctor's part I don't know what is. Even at 17 cm his residual AHI >12 on avg, many nights double that. It is not they blew his titration it is they blew $3k grand on a wasted study because they didn't find therapy that brought his condition down to therapeutic levels.

IF he is already at 17 cm pressure and under treated if his tongue gets lodged the machine won't have the range it needs to dislodge it, obviously it doesn't have the ability to prevent any apnea. If the lab can't find a pressure they need to give him a Bipap Auto and let it find it on its own.

Ask this guy how many months it has been since he first seen his doctor about fatigue, I bet its been 6 months already. He is going to need much higher pressure than his current machine can deliver.

[ozij]

At this point, there's no reason to think the titration was "blown".

Some insurance companies will agree to pay for a bi-level machine only after failure on fixed pressure is proved. So you were given fixed pressure at 15 - which left you snoring, and fixed pressure at 17 - which solved snoring and made the AHI better, but far from good enough.

http://www.aasmnet.org/Resources/Practi ... essure.pdf

Bi-level therapy is a guideline recommendation, not a standard.

4.5.1 While the literature mainly supports CPAP therapy, BPAP is an
optional therapy in some cases where high pressure is needed and
the patient experiences difficulty exhaling against a fixed pressure
or coexisting central hypoventilation is present (Guideline).
This recommendation is based on 2 Level I studies81,82 which
yielded no evidence that BPAP improves efficacy or adherence
in the management of OSA compared to CPAP [7.2.2]. APAP is
also a treatment option; however, this was not incorporated in the
accompanying review paper since an earlier review and practice
parameters for APAP was published in 2002.83

O.

WHO said it was a Standard YOU? sure and the hell wasn't me.

Of course it wasn't YOU, Snoredog. It was the American Academy of Sleep Medicine. Anyone can click on the link I gave, and read the whole text.

2 studies already how many more do you need?

The first was full night's PSG to find if he had sleep apnea. He does.
The second was a full night't titrations study on fixed pressure.

I think one more, a bi-level titration can help.

The guy's residual OSA qualifies for Severe OSA treated.

Yes, of course it does.

Some insurance companies will agree to pay for a bi-level machine only after failure on fixed pressure is proved. So you were given fixed pressure at 15 - which left you snoring, and fixed pressure at 17 - which solved snoring and made the AHI better, but far from good enough.

He is going to need much higher pressure than his current machine can deliver.

Once again, you've hit the nail on the head, Snoredog.

It's like I've been saying from my very first post on this thread, sleepytexan, you need a bi-level machine. I was also trying to point out that your docotor's procedure of treating you was following the practice parameters of the American Academy of Sleep Medicine - and therefore I don't consider that a reason to distrust the doctor. Which is not to say I consider the results satisfactory.

As a matter of fact, I also said the following in the above post:

Fixed pressure doesn't work for you - and make that very very clear to your doctor. You have no reason to stick to the present Rx - but that doesn't mean your doc. should be distrusted.

O.

[sleepytexan]

Hey Guys,

Thanks for the posts and feedback.

I really like my Dr. (he is a GP) but I think he is VERY ignorant of this stuff. The people I do wonder about is the sleep lab and doctors there. I am going to go back to my GP and fill him in with all of my acquired knowledge (thanks to you guys and this site) and see if he will schedule another sleep study. I will also question his choice of labs.

I noticed that there are a couple of different bi-level PAPs. One is automatic (and more expensive). What is the difference and what do you recommend I speak to him about? The good news is my insurance covers the sleep studies 100%. The bad news is that, because of my high deductible, I have to pay for the equipment 100%. I am also not sure if it is too late to turn in my CPAP and upgrade or if I will have to eat that cost. Either way, I want to pursue the most beneficial treatment without having to go back. Please let me know what you think....

Thanks,
Doug