Help with diagnostic & titration PSG / Do I have CSA?

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
jcb1
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Help with diagnostic & titration PSG / Do I have CSA?

Post by jcb1 » Wed Apr 13, 2011 2:11 pm

Hello. I was recently diagnosed with sleep apnea and have been using a DeVilbiss InteliPap Auto (with Swift FX) for a few weeks. At first I did feel better in the morning but now I feel like it is worse (both the feeling when waking up and the daytime sleepiness). I had a full night diagnostic PSG (posted below) and a titration study. The titration study resulted in a recommended pressure of 7. I was told that I had about 2 hours in supine on 7 with only one apnea. My doctor prescribed an F&P Icon Auto set at 4-12. Due to high cost with the DME, I decided to purchase the DeVilbiss machine online. My doctor did loan me a F&P Icon Auto and I used it for a week (set at 4-12) with what seems like better results than with the DeVilbiss machine (although I am not certain). My doctor is allowing me to make pressure adjustments and what I have found is that I sometimes feel better and get better numbers with the SmartLink software when I am limited to lower pressures (4-7) but it still seems to vary a lot per night. I don't think I have much of an issue with leaks.

In the SmartLink reports, I'm seeing a problem with Hypopneas. I'll have 1 or 0 obstructive apneas, maybe 2 to 4 NRI events (which I am assuming are central apneas) and maybe 20-30 hypopnea events.

Here is an example... my pressure setting was 4-7, average was 4.4, median 4.0, max 6.6, 90 & 95% was 6.0
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Here is another example... my pressure setting was 5-9, average was 6.7, median 6.4, max 8.9, 90 & 95% was 9.0
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Also, until reviewing my PSG (posted below) I thought I had OSA. This is what the doctor had spoken with me about (prior to the sleep studies) and after the study nothing was mentioned on exactly what the diagnoses was. I just assumed that I had OSA since my doctor prescribed an Auto CPAP. It looks like I didn't have enough obstructive apneas for an OSA diagnoses but I did have a lot of central/mixed events. This is where I get really confused. I thought, from reading the forums, that CSA was treated with an ASV type machine and a CPAP was not very effective. Obviously my doctor saw the large number of central events on my study. Is it likely that he thinks I will be fully treated on an auto CPAP? Why wouldn't he prescribe an ASV machine? Do I even have CSA? I don't yet have the summary report from my titration study. I've asked the doctors office for it and they told me they will get it to me soon, but the doctor needs to "finish it". I tried to pick a good doctor. He is a neurologist that is board certified in sleep medicine.

I'm having a really rough time with this treatment and I really appreciate any advice on what direction I should go in. I realize some things take time, and I'm willing to take long term advice or give my current treatment more time. I've gotten use to sleeping with the mask, but I feel like I might feel better sleeping without it at this point. I really want to make this therapy work. Thanks for any advice.


Patient: XXXXXXXXXX
DOB: XX/XX/XXXX
AGE: 29
Gender: Male

Diagnostic Polysomnogram

Major Findings and Recommendations:

SUMMARY: No evidence of Possible Clinically significant obstructive sleep apnea syndrome (327.23).
The apnea-hypopnea index was 24.4 events/hour consistent with moderate disease. Apnea was much worse during supine position. Drops in oxygen saturation were moderate: the SaO2 nadir was 85%. The percent of study time spent with oxygen saturation below 88% was 0.1%.

No evidence of clinically significant periodic limb movements of sleep.

Sleep quality was preserved despite respiratory events.

STUDY LIMITATIONS: Because the patient had trouble falling and staying asleep, this study may be underestimating the severity of an intrinsic sleep disorder. This sleep study is only one component of the patient’s evaluation and clinical correlation is necessary.

RECOMMENDATIONS: Clinical correlation. Positive airway pressure titration.


STUDY TIME:
Start Time: 9:28 PM
End Time: 5:05 AM
Time in Bed: 457.4 minutes
Total Sleep Time (TST): 351 minutes

SLEEP STAGE ANALYSIS:
Sleep Efficiency (sleep time / study time) x 100%: 76.8%
Sleep Latency (time in min. to any sleep): 9.28
Wake Time after Sleep Onset (WASO) in min.: 97
Stage N1 (percent of TST): 12.7%
Stage N2 (percent of TST): 59.6%
Stage N3 (percent of TST): 13.4%
REM Sleep (percent of TST): 14.4%
REM Latency (min. after sleep to first REM): 156


OXYGEN:
Oxygen Saturation at Baseline: 99.0%
Lowest Oxygen Saturation Non-REM: 85.0%
Lowest Oxygen Saturation REM: 89.0%

RESPIRATORY EVENTS:
Number of Oxygen Desaturations: 149

Obstructive Events: 5
Obstructive Events Respiratory Index Non-REM: 0.8
Obstructive Events Respiratory Index REM: 1.2

Central/Mixed Events: 138
Central/Mixed Events Respiratory Index Non-REM: 23.2
Central/Mixed Events Respiratory Index REM: 26.4

Desaturation index (number / hour of sleep): 25.5
Desaturation index (number / hour of sleep) Non-REM: 25.2
Desaturation index (number / hour of sleep) REM: 27.6

Apnea / Hypopnea index (AHI) (number / hour of sleep): 24.4
Apnea / Hypopnea index (AHI) (number / hour of sleep) Non-REM: 24.0
Apnea / Hypopnea index (AHI) (number / hour of sleep) REM: 27.6


SLEEP STAGES:
Stage N1: 44.5 min.
Stage N2: 209.2 min.
Stage N3: 47.0 min.
Stage REM: 50.5 min.
Wake: 106.3 min.

BODY POSISTION:
Left: 18.1%
Prone: 21.2%
Right: 48.9%
Supine: 11.3%

OXYGEN SATURATION:
Maximum: 99.0%
Minimum: 0.0%
Mean: 95.9%
PULSE:
Maximum: 100.0
Minimum: 58.0
Mean: 74.5

ELECTROCARDIOGRAM DATA:
ECG from a single lead showed sinus rhythm. Mean heart rate was 74.5 and ranged from 58 to 98. Expected heart rate variability accompanying oxygen desaturation.

ELECTROMYOGRAM DATA:
Electrodes attached to both tibialls muscles showed no periodic limb movements in sleep.

QUESTIONNAIRE DATA:
The patient completed a questionnaire before the polysomnogram recording. Epworth sleepiness scale was 3 points out of a maximum of 24 consistent with no excessive daytime sleepiness. The night of the study was described as much worse than a typical night’s sleep at home.

Based on all of the available data, I believe that the current study is adequately representative of the patients normal sleep physiology. As such, it is a reliable diagnostic test.

(DOCTOR’S SIGNATURE)
(credentials)

Patient was studied at <Name of Sleep Clinic>. Standard polysomnographic recording channels were employed, including electroencephalogram, electroculogram, electrocardiogram, submental electromycogram, respiratory effort (chest and abdominal), anterior tibialis electromyogram, position sensor, airflow and pulse oximetry. Technician observations were recorded continuously throughout the recording. The entire recording was reviewed by a board certified sleep disorders specialist and was scored using standard criteria. Any respiratory event, recorded in the flow or effort channels greater than 10 seconds which were associated with an EEG arousal, bradycardialachycardia ECG pattern or a 4% desaturation (3% if baseline oxygen saturation was below 93%) was counted for the determination of the Apnea-Hypopnea index (AHI).
Last edited by jcb1 on Thu Apr 14, 2011 5:49 pm, edited 1 time in total.

jnk
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Re: Help understanding PSG / Do I have CSA?

Post by jnk » Wed Apr 13, 2011 2:29 pm

Maybe the doc is just trying to see what helps?

The charts and detailed information from your titration, showing how your body reacted to the application of PAP at different pressures, may be more useful information than the summary information from your diagnostic study.

For many of us, the first few weeks are mostly about getting used to sleeping with the mask and machine. So some docs try a lower-than-optimal pressure at first and raise it later. For some of us, the mixed/central events go away with the application of CPAP, so ASV may not be tried right away even if it seems likely a patient may end up using one eventually. The doc has to see what works before deciding what won't work.

Don't necessarily judge the likelihood or unlikelihood of long-term success by how you feel a few weeks in. If after several weeks you still don't feel any better, changes may need to be made.

Any chance you can link to a shot of the detailed graphs and charts of your titration (with all personal and identifying information blocked out, of course)? That may give posters more experienced than I what they need to give more helpful advice.

nrgsan

Re: Help understanding PSG / Do I have CSA?

Post by nrgsan » Wed Apr 13, 2011 6:28 pm

JNK, Thanks for your response.
jnk wrote:Maybe the doc is just trying to see what helps?
I guess that is most likely. I have another appointment with him next week and will find out. Its just that I've spent $1700 on this doctor so far and it doesn't seem that he wants to do much more after the studies. I might need to find another doctor.
jnk wrote:The charts and detailed information from your titration, showing how your body reacted to the application of PAP at different pressures, may be more useful information than the summary information from your diagnostic study.
Agreed. I have asked them for the summary of the titration. I'm told as soon as the doctor finishes it they will email it to me.
jnk wrote:For many of us, the first few weeks are mostly about getting used to sleeping with the mask and machine. So some docs try a lower-than-optimal pressure at first and raise it later. For some of us, the mixed/central events go away with the application of CPAP, so ASV may not be tried right away even if it seems likely a patient may end up using one eventually. The doc has to see what works before deciding what won't work.
Well, if I can trust the DeVilbiss machine to detect the central events (as the manual says it does as "NRI"), then it is taking care of the centrals. I may only have 4 per night now and maybe 1 obstructive event. The issue now is that I have a lot of hypopnea events (20+). I had only one hypopnea event during the first PSG. I feel about the same and sometimes worse in the morning and daytime. I feel like I'm use to sleeping with the machine now. I don't wake up during the night any more and I don't take the mask off or open my mouth. I'm surprised at how well I've taken to it.
jnk wrote:Don't necessarily judge the likelihood or unlikelihood of long-term success by how you feel a few weeks in. If after several weeks you still don't feel any better, changes may need to be made.
I want that to be true. My doctor told me that by now usually people feel better or at least make some progress. He gave me a prescription for Nuvigil and basically said that I may never feel better. I might need to find a different doctor.
jnk wrote:Any chance you can link to a shot of the detailed graphs and charts of your titration (with all personal and identifying information blocked out, of course)? That may give posters more experienced than I what they need to give more helpful advice.
I will post it as soon as I get it.

jnk
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Re: Help understanding PSG / Do I have CSA?

Post by jnk » Wed Apr 13, 2011 6:52 pm

nrgsan wrote:
jnk wrote:The charts and detailed information from your titration,
I have asked them for the summary of the titration.
Try to get detailed info, not just summary, if you can.

Diagnostic studies are mostly made to prove to insurance that something should be tried. It is the titration study, in my opinion, that gives the most valuable information to us as patients, because it shows how you react to pressure.

That being said, once it is determined that PAP doesn't worsen breathing and sleep, the thing that matters most is response to therapy--meaning feeling better.

Problem is, most of us need to relearn how to sleep once we can. That means our straightening out our "sleep hygiene" becomes as big a test for many of us as sleeping with the equipment.

I hope you get to the bottom of it all. Keep posting questions on this board. It may not be your first question, your second, or your third that strikes a chord with the board, but eventually you will ask the exact right question and get the most helpful information. Posting titration charts usually gets an observation or two.

If a doc told me I might never straighten out my sleep and health, I might take that as code for "I ain't the right doc to know how to help you, so I won't be offended if you look for another." That doesn't (or shouldn't, IMO) mean more sleep TESTS. It means trying different TREATMENT approaches. (Once it is established that your breathing isn't the best at night and that pressure doesn't make things worse, sleep tests have mostly done their job, in my uneducated opinion as a fellow patient.) Then it's time to start trying things to help sleep in general and health in general, and any testing should be for something other than just trying different pressures or proving over again that things aren't the best.

@forum: Anyone else have opinions out there on this stuff, gang? Don't assume I have any idea I know what I'm talking about. I'm just winging it here . . .

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Pugsy
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Re: Help understanding PSG / Do I have CSA?

Post by Pugsy » Wed Apr 13, 2011 7:26 pm

jnk wrote:@forum: Anyone else have opinions out there on this stuff, gang? Don't assume I have any idea I know what I'm talking about. I'm just winging it here . . .
I have read this and reread it and just can't come up with anything other than this is just weird.
jcb1 wrote: SUMMARY: No evidence of Possible Clinically significant obstructive sleep apnea syndrome (327.23).
The apnea-hypopnea index was 24.4 events/hour consistent with moderate disease. Apnea was much worse during supine position.
AHI 24.4 sure warrants a diagnosis
jcb1 wrote:STUDY LIMITATIONS: Because the patient had trouble falling and staying asleep, this study may be underestimating the severity of an intrinsic sleep disorder. This sleep study is only one component of the patient’s evaluation and clinical correlation is necessary.
jcb1 wrote:Total Sleep Time (TST): 351 minutes
351 minutes isn't enough?? Unless there was so much fragmented sleep but they were able to spot
jcb1 wrote:Central/Mixed Events: 138
Unless this is what was meant by the "No evidence of Possible Clinically significant obstructive sleep apnea syndrome"
jcb1 wrote: Obstructive Events: 5
Obstructive Events Respiratory Index Non-REM: 0.8
Obstructive Events Respiratory Index REM: 1.2
Maybe the Central/ Mixed events what the AHI is predominantly based on. The math works.

Obviously it doesn't appear that the APAP is working well. What to make of it? I don't know. Is this a fishing expedition to be failed to warrant the high end ASV machine? I think some very straight forward questions need to be presented to the doctor about what the implications are from the machine's data that is seen and what course of action and options are to be considered. Titration study results might shed some light on things but the APAP results aren't optimal and I don't have expertise to advise in a situation like this. Straight cpap maybe?

Other than asking more questions, I am not much help. Sorry. Where is JohnBFisher or the others that have more experience and knowledge with this type of history.

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jnk
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Re: Help understanding PSG / Do I have CSA?

Post by jnk » Wed Apr 13, 2011 7:49 pm

Pugsy wrote: I have read this and reread it and just can't come up with anything other than this is just weird.
Thanks, Pugsy. That makes me feel better! Let's hope the titration information shows something understandable.

jcb1
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Re: Help understanding PSG / Do I have CSA?

Post by jcb1 » Wed Apr 13, 2011 9:53 pm

Pugsy, thanks for your response. I really appreciate it.
Pugsy wrote: ...Straight cpap maybe?
I've tried CPAP mode set at 7 (my titrated pressure) with almost identical results.

I'm going to keep my lower pressure settings (5-9) for now as that seems to be the best so far. I will try to address all of these concerns with my doctor next week. Hopefully he can provide my titration study by then.

I will "hang in there". It just seems like I've stirred up so much by starting this therapy. Before PAP I was better able to be in denial about my condition. Now that the denial is over, its just depressing not knowing the best course. I can't seem to learn quick enough.

I really appreciate all comments and suggestions. This is a great forum and I have already learned a lot. Thanks!

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Pugsy
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Re: Help understanding PSG / Do I have CSA?

Post by Pugsy » Thu Apr 14, 2011 7:49 am

Please keep us posted as to how things are going and what the doctor says. Wish I could offer more than support but my usual responses to run of the mill basic OSA problems don't apply to you so my bag of tricks is empty.

I do understand your frustrations though when what is supposed to help you seems to make you feel worse and there is no clearly identified beast to tame.

So bumping this thread again in hopes of catching the eye of those more knowledgeable in this area.

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jcb1
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Re: Help understanding PSG / Do I have CSA?

Post by jcb1 » Thu Apr 14, 2011 4:53 pm

Pugsy wrote:Please keep us posted as to how things are going and what the doctor says...
Thanks again. I will keep reading the forums and will post what my doctor says next week.

Does anyone have similar experiences or have any ideas on what I can do for my hypopnea issue?

jcb1
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Re: Help understanding PSG / Do I have CSA?

Post by jcb1 » Thu Apr 14, 2011 5:48 pm

I just got my titration PSG summary emailed from the doctor. I really appreciate it if anyone can help me understand it based on my original post. Thanks!

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Pugsy
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Re: Help with diagnostic & titration PSG / Do I have CSA?

Post by Pugsy » Thu Apr 14, 2011 6:49 pm

Most of the titration study results are self explanatory. Looks like on paper you did better at cpap 7 cm but you aren't doing that now. I don't have any idea why.
Looks like the APAP trial is a fishing expedition and the results and follow up may offer you some answers to your questions. I would make sure I wrote down all my questions and go over the list with the doctor. It has been my experience that I sometimes forget all my questions... Tell doctor that you want to understand what you are seeing.
If he says "don't worry about so and so" and you wonder why, then ask why. Some doctors are good at explaining, some aren't.

Did you have something specific in the study that you were wondering about?

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jcb1
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Re: Help with diagnostic & titration PSG / Do I have CSA?

Post by jcb1 » Thu Apr 14, 2011 7:02 pm

Pugsy wrote:Most of the titration study results are self explanatory. Looks like on paper you did better at cpap 7 cm but you aren't doing that now. I don't have any idea why.
Looks like the APAP trial is a fishing expedition and the results and follow up may offer you some answers to your questions. I would make sure I wrote down all my questions and go over the list with the doctor. It has been my experience that I sometimes forget all my questions... Tell doctor that you want to understand what you are seeing.
If he says "don't worry about so and so" and you wonder why, then ask why. Some doctors are good at explaining, some aren't.

Did you have something specific in the study that you were wondering about?
Thanks again. I guess I just need to wait to see the doctor to find out more. I'm wondering if my condition just varies from night to night and I happened to have a good night during the titration study. Or maybe the since the equipment I'm using is different, it is not working as well?

jcb1
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Re: Help with diagnostic & titration PSG / Do I have CSA?

Post by jcb1 » Fri Apr 15, 2011 10:44 am

I have been noticing lately that I wake up and feel like I can not breath enough through my nose (Swift FX). I do have an issue with nasal congestion. Its a stuffiness that's always there. I do saline irrigation and that seems to have no effect. I didn't think it was that bad. I just ordered a Mirage Liberty so I can breathe through my mouth sometimes. I wonder if the nasal congestion has anything to do with my hypopnea issue. Could it be as simple as a mask issue?

jnk
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Re: Help with diagnostic & titration PSG / Do I have CSA?

Post by jnk » Fri Apr 15, 2011 10:59 am

jcb1 wrote:I have been noticing lately that I wake up and feel like I can not breath enough through my nose (Swift FX). I do have an issue with nasal congestion. Its a stuffiness that's always there. I do saline irrigation and that seems to have no effect. I didn't think it was that bad. I just ordered a Mirage Liberty so I can breathe through my mouth sometimes. I wonder if the nasal congestion has anything to do with my hypopnea issue. Could it be as simple as a mask issue?
With nasal pillows, I need at least 8 cm of pressure to feel like I can breathe. When my allergies flare up, I sometimes need as much as 10 cm of pressure to feel like I am getting enough air.

Pressure is about treating a condition, but it is also about comfort. If increasing the pressure makes me more comfortable and doesn't increase my reported AHI, I assume that increasing the pressure is not hurting my therapy. If raising the pressure increased my AHI in any significant way, I would put the pressure back down and talk to my doc about it.

It is counterintuitive to think that raising pressure can make a patient more comfortable, but for me and some others I've spoken to, that is the case.

The main goal starting out is keeping leak low as you get comfortable using the mask and machine. After that, it may be time to find the one pressure you are most helped by and most comfortable at.

jcb1
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Re: Help with diagnostic & titration PSG / Do I have CSA?

Post by jcb1 » Wed Apr 20, 2011 3:23 pm

Ok, the Mirage Liberty didn't seem to make a difference other than it was less comfortable than the Swift FX.

I saw the doctor and asked my questions from this thread. He basically told me that the 138 number is for "central/mixed" events - not necessarily central only. He told me that all of my events started with an obstructive component and since there was also a central component they tally it under that heading so that insurance companies will likely pay for any treatment that they want to try.

He thinks that my APAP therapy not being optimal is due to the differences in algorithms between manufactures. I did well during my titration study with a ResMed machine and I remember feeling rested on some days using the F&P Icon Auto that he loaned me (for a week). I had purchased a DeVilbiss Intelipap Auto and was not feeling rested when I woke up. I am not sure if my condition just varies from night to night and I happened to have good nights for the titration and first week of at home use or there is something different about the DeVilbiss machine. He loaned me the F&P Icon auto to try again for a week to see how I feel. He said I can try an ASV machine next if it doesn't improve. So far, with one night on the borrowed machine, I feel the same or worse (still tired in the morning). I really would like an APAP to work for me. I'm not sure how I will be able to afford an ASV machine.

How does this sound to everyone? Is it likely that I can not do well on a DeVilbiss machine but do better on an F&P machine? Could it just be that my condition varies? I guess I will find out this week. Any comments or suggestions are highly appreciated!