auto cpap in lieu of second sleep study

[greyhound]

A friend was recently diagnosed with moderate sleep apnea (7.4 AHI). Rather than incurring the costs of a second sleep study, he is thinking about getting an auto cpap.

Unfortunately, I can't locate the older threads that I know discussed ways of using an auto cpap to determine the appropriate settings. Can anyone lead me to those threads or suggest ways to use an auto cpap in lieu of a second sleep study.

[WAFlowers]

During a titration the repiratory tech is attempting to determine the lowest pressure which will prevent apneic events. Now apply that concept to a self-study with an APAP with software (I really don't believe it can be done properly without software).

Start with a moderately low pressure range (6 to 10 maybe) and try that for a night. If the software indicates that your friend is spending most of the time at the top of the range and there are still lots of events, move the range up. Keep doing this until you satisfy the requirments listed in the first sentence. Also watch for central apneas which can sometimes occur in some people at higher (relative to need) pressures.

Note that I am not a doctor or a respiratory tech and my suggestions have no basis in any training. Just apply common sense.

[kikisue]

Here's a link to rested gal's experiences - she is the expert, from what I've seen, on this, having worked with all three major auto machines.
viewtopic.php?t=5778&highlight=sleep+study
The sleep study does tell you more than just pressures, so glad you did have the initial study to see if you had other issues - PLMS, etc.

Once you've had some time with it, do keep us posted with questions, results etc. There are a lot of very experienced folks here who can help you figure it all out.

Regards,
Karen

[Bonnie]

During my initial sleep study I couldn't tolerate the mask for the titration. My doctor set me up with a cpap at 7 and mask so I might adjust and get use to it. He then wanted to do another sleep study but I couldn't afford the cost or the time. He said an auto cpap at home for a week would be his 2nd choice, which is what we did. (During that time I really liked the auto) He determined my pressure should be 11 and after bugging him about an auto he finally relented and wrote the script. I downloaded the software, bought the card reader and with the help of people here with installing it...I am now monitoring my events and tracking my treatment.

I agree with Karen, Restedgal is extremely knowledgable and always willing to share.

Your friend will need a prescription to purchase a machine, be it thru a DME or on line, insurance or out of packet.

[Linda3032]

7.4 AHI is really quite low (I believe). Forum, please correct me if I'm wrong. I fought against therapy and mine was 50 AHI or more. ...

Is your friend really sure he/she wants to do CPAP therapy with a low AHI?

And, will a doctor write a prescription for that low?

[NightHawkeye]

7.4 AHI is really quite low (I believe). Forum, please correct me if I'm wrong.

Yes, but . . . AHI's are not equal. If all apneas were equal, then AHI would be a truly objective measure. A person can mostly have short apneas and a high AHI without having any real problems. Conversely, a person can have long apneas with a low AHI and have serious problems. The scoring system kinda takes this into account, but has an arbitrary cut-off for Medicare at AHI = 5.

Regards,
Bill

[greyhound]

If you're tired all the time and have trouble sleeping, I think cpap is worth a try, despite a 7.4 AHI. Surprisingly (maybe, not so surprisingly), it's cheaper to buy an apap than get a second sleep study and rent a machine for a few months. Worst case, you discontinue using it and it hasn't cost you much more than the second sleep study would have.

[Linda3032]

Nothing of this pertains to me as I'm 100% covered by insurance plus supplements.

Obviously, if a person is very tired, with headaches, etc. then they should try therapy - even with a low AHI. It was just a little surprising to me that someone would "want" therapy with a low AHI.

My other thought was, Wouldn't it be a problem to get a prescription from a doctor?

[NightHawkeye]

It was just a little surprising to me that someone would "want" therapy with a low AHI.

Linda, don't fall into the trap of believing a low AHI means people don't have real apnea problems. Like most of us here, people only want this therapy if they're having a problem.

Regards,
Bill

[Janelle]

Yes, I agree AHI numbers don't mean a heck of a lot. Mine was about 2.4, but then I never slept for more than an hour, never acheived deep sleep or REM sleep, but I obviously had OSA as diagnosed by an ENT. And my oxygen desat rates went down to the low 80s. I was titrated at 9 at the titration, because they did not do a split night the first time, as my AHI wasn't high enough. That night I slept all the way through except for getting up one time, thanks to Ambien. But still my AHI was relatively low and not diagnostically correct for Sleep Apnea. But 8 was as effective as 9. My lovely Dr. put me on an APAP right away.

I guess my point is this, an APAP can only do so much, like adjust pressures to what you need, but it is not infallilble. Leaks will cause it to go to higher pressures, it doesn't show oxygen desat rates, it doesn't show sleep stages or the lack thereof. It doesn't show Restless Leg Syndrome, it doesn't show the position you were sleeping in, all of which are shown on a Sleep Study. If you are mouth breathing during a sleep study, the tech will slap a different mask on you or a chin strap. At home, you may not even know if you are mouth breathing or for how long, another leak (major) that will affect the pressure on an APAP.

If your friend does skip the second sleep study and goes the APAP route, he might do perfectly fine. But if he still doesn't feel rested after several months, he might still have to have another sleep test to determine WHY.

Often sleep studies don't give an accurate picture of our problems either since it is only one night and sleep can vary widely from night to night, depending on the stimulation you had during the day, how deeply your sleep, how long it takes you to get to sleep, how much sleep you have lost over the months or years, or even the day before. And some people just can't sleep in a strange bed as well as they can at home.

Your friend might also have a talk with the Dr. and tell him, he really can't afford another Sleep Study and that he would like to be able to borrow or buy an APAP to titrate himself at home (often Drs have machines for loan for this very thing). It would be a good idea for him to also borrow one of those thingees to put on his finger at night which will monitor oxygen desat rates for a better picture. This way, he could be out very little money and get the same results, and also might decide if he really wanted to put out the money for an APAP machine. It might even turn out he really needs a BiPap, if his pressure are high.

[Guest]

My other thought was, Wouldn't it be a problem to get a prescription from a doctor?

I think that depends on the doctor. Some will write a prescription if you ask for it and some won't. It is a problem for insurance. An AHI under 5 does not qualify for a clinical diagnosis of OSA, so insurance will not cover the cost.

A PSG which determines one's AHI is the best means available for diagnosing sleep apnea. I have to agree with you, Linda. If mine were that low I sure wouldn't be asking for CPAP therapy either! Some in the sleep medicine medical community have even suggested an AHI under 10 doesn't warrant CPAP therapy. Sleep doc guru, Dr. Ropoport stated the following:

Obstructive sleep apnea symptoms are also likely to be severe enough to warrant treatment in patients with an AHI of about 20 per hour; SDB can probably be ruled out at an AHI of about 10 per hour.*

It is certainly possible there are people out there using CPAP therapy who don't need it, but asked for a prescription for it anyway. That's their prerogative. It's basically harmless, so if they want to try it, why not? Maybe they will feel better and it will have been worth the trial. For the skeptics out there; even if it is a placebo effect, feeling better is feeling better. You can't put a pricetag (or apnea/hypopnea index) on that!

*THE APNEA-HYPOPNEA INDEX: USEFUL OR USELESS?



-LC

[NightHawkeye]

An AHI under 5 does not qualify for a clinical diagnosis of OSA, so insurance will not cover the cost.

According to Medicare guidelines. Individual insurance coverages vary.

A PSG which determines one's AHI is the best means available for diagnosing sleep apnea.]

Certainly the health industry standard, but not infallible. I know from experience. I had two PSG's and they both missed the diagnosis.

I have to agree with you, Linda. If mine were that low I sure wouldn't be asking for CPAP therapy either! Some in the sleep medicine medical community have even suggested an AHI under 10 doesn't warrant CPAP therapy.

OK, let's say for instance that you felt lousy for the past ten years, were always tired and had just killed somebody after falling asleep at the wheel, but only had an AHI of 4.7, according to a PSG, what would your attitude be then, LC?

Regards,
Bill

[Guest]

OK, let's say for instance that you felt lousy for the past ten years, were always tired and had just killed somebody after falling asleep at the wheel, but only had an AHI of 4.7, according to a PSG, what would your attitude be then, LC?

What would my attitude be? I can't say for sure, Bill. My guess would be I would become highly irrational, accusatory, antagonistic and defensive. But that's only a guess.

If I had just killed somebody after falling asleep at the wheel, but only had an AHI of 4.7, I would explore, with the assistance of my doctor, the possibility of narcolepsy or idiopathic hypersomnia, or cataplexy, or any other potential diagnosis, since OSA had been ruled out.


-LC

[NightHawkeye]

If I had just killed somebody after falling asleep at the wheel, but only had an AHI of 4.7, I would explore, with the assistance of my doctor, the possibility of narcolepsy or idiopathic hypersomnia, or cataplexy, or any other potential diagnosis, since OSA had been ruled out.

That's certainly reasonable, LC, if a little absolute. So, let's say after another few years you had explored all these possibilities, but you had, in between visits to physicians, done a little experimenting on your own and gotten some credible evidence suggesting that you might just have sleep apnea after all, would you take matters into your own hands and just buy a CPAP machine, even if you had to pay for it out of your own pocket, or would you continue to listen to all the "medical experts" who despite your years of office visits and testing had been unable to either relieve your symptoms or come up with a definitive diagnosis?

The reason I ask is because for me this was not so much a hypothetical situation. I believe I already mentioned that I had two PSG's which missed the diagnosis. What I haven't mentioned is the fact that over the years, I've been referred to cardiologists, neurologists, psychiatrists, endocrinologists, rheumatologists, gastroenterologists, pulmonolgists, and a few other 'ists I can't remember, multiple times for most in fact, as another potential diagnosis might occur to one of these guys.

Mostly though I just ignored it for years, and coped as best I could, until one day, not so long ago, I realized that these guys had no magical diagnostic powers and that diagnostic equipment was readily available within my price range and that if I was going to resolve my problem, I was just going to have to do it myself.

So what do you think, LC? What would you do if you had followed all the leads you've mentioned but came up with nothing? Would you do like I did? Or perhaps there is another possibility that I might have missed?

Regards,
Bill

[Guest]

Bill, If I had exhausted all other possibilities through medical diagnostics, (including those I referenced in my previous post) I would move heaven and earth to find a solution on my own. If I was experiencing sleep disturbances to the point where I felt lousy for the past ten years as you have, and my personal research lead me to believe I suffered from OSA, I would most definitely buy a CPAP out of pocket and try therapy for six months to see if it made a difference in how I felt. As I mentioned earlier, even if feeling better on CPAP was due to the placebo effect, feeling better is feeling better, regardless of your AHI.

You asked if there are other possibilities you may have missed, and there may be, but I would enlist the aid of a doctor. Medical expertise could greatly enhance your personal research. Have you examined your sleep architecture? In some of your previous posts you wrote:

As background, I'll add that I'm 53 now and have had sleep problems for 27 years due to heart arrhythmias, bradycardia, hypothermia, leg cramps, chest pain, edema, etc. The episodes were always transient though. I've lost count of exactly how many trips were made to the emergency room in the middle of the night, but it's in the six to ten range, mostly in an ambulance. Always the same result, although the diagnoses varied greatly. Sometimes I even got a stress test. Heart was always just fine. Sometimes I left the hospital after a few hours feeling better than I'd felt in weeks.

I'd obtained a pulse oximeter and analysis software for home use to keep tabs on oxygen desaturation at night. The results showed desaturations which coincided with the arrhythmias, or more precisely, preceded the arrhythmic events just slightly. Desaturations occurred pretty much non-stop on the few occasions when I was able to fall asleep while lying on my back.

My dreams often start out pleasant enough but always end in a crisis as I awaken with hypoxia/arrhythmia/cramps/etc.

I also tend toward hypothermia at night with a basal temperature 2-3 degrees below normal. I was diagnosed with hypothyroid years ago but supplements have never made much difference in body temperature although I continue to take them (and every year I get a thyroid test and am told everything is "normal"). Many nights I've awakened to uncontrollable shivering. (Believe it or not, I'm actually relieved when I get a fever, because I'll be warmer at night; I'll sleep well without having to worry about waking up in a crisis.)

This would indicate you have many other health issues contributing to disturbed sleep, independent of possible OSA. How severe are your oxygen desats? You said your "heart was always just fine." Were your emergency room visits diagnosed as panic attacks? Is it possible medications you are taking could be effecting your sleep? Do you have the sleep architecture graph from your sleep study? Perhaps you aren't getting the REM sleep you need. You have mentioned that you believe Encore Pro's 'variable breathing' is a good measure of REM. By Respironics' definition, variable breathing occurs during wakefulness, distress and REM sleep. The percentage of variable breathing you see could be an indication of distressed sleep (which would be in keeping with your above detailed medical problems) and not necessarily an indication of REM sleep. Perhaps this is an issue you might want to investigate further. This discovery made all the difference for Janelle (and her PSG also indicated a very low AHI).

Good luck to you.

-LC