confused by titration study results

So, the short version: had my first sleep study: AHI 41.2, with 14 obstructive apneas and 193 obstructive hypopneas, all events recorded in all positions. Oxygen average 97%, minimum 92%, no PLMs. The Dr. classified me as Moderate because, even though my AHI was high, my oxygen was relatively good.

So, on to the titration study: it was determined that a pressure of 6 reduced my events to 3.7. (They startyed me at 5, which got me down to 15.4 events.) They kept increasing the pressure, and at 10 I had 0 events. (As I also did at 11-14. The Dr. said they shouldn't have done those--should have let me sleep--wish they had!)

So, today I went to my appointment expecting to come home with a machine, but no. She said first that I should try to loose weight: she said w/ such a low pressure I might not need CPAP at all if I were thinner (I am overweight but not obese.) I said I would try, but since that wouldn't happen right away, I thought we should proceed w/ CPAP, figuring if I were more awake I might be more active, loose weight... She agreed. She had never heard of the Hybrid mask (!), but was happy to order it for me, since she liked the look of it (I brought the printable brochure). So now, I have another appointment a week from Friday for equipment setup.

My question is: Does the fact that my pressure need is so low suggest I might benefit from somnoplasty or Pillars? Upon finding my AHI was so high, I'd resigned myself to CPAP, but if it isn't necessary, I would prefer something easier.

What do you think?

Your appointment today - was that a doctor or a DME provider that said that to you? I'm still reeling from the fact that they thought you should lose weight BEFORE starting CPAP - it's frightening to me how uneducated that person obviously is.

Today's appointment was with the sleep doctor: Board certified in Pulmonary, Critical Care, Sleep and Internal Medicine (as per her card). I told her I thought I should start on the CPAP so as to get the energy to lose weight....She agreed it might help. Her office seems quite disorganized, too. I have a call in to both my PCP and the ENT who referred me for sleep study. Perhaps they can refer me to someone else.

svh wrote:So, the short version: had my first sleep study: AHI 41.2, with 14 obstructive apneas and 193 obstructive hypopneas, all events recorded in all positions.

So, on to the titration study: it was determined that a pressure of 6 reduced my events to 3.7. (They startyed me at 5, which got me down to 15.4 events.) They kept increasing the pressure, and at 10 I had 0 events.

So, today I went to my appointment expecting to come home with a machine, but no. She said first that I should try to loose weight: she said w/ such a low pressure I might not need CPAP at all if I were thinner (I am overweight but not obese.)

My question is: Does the fact that my pressure need is so low suggest I might benefit from somnoplasty or Pillars? Upon finding my AHI was so high, I'd resigned myself to CPAP, but if it isn't necessary, I would prefer something easier.

What do you think?

I think a new doctor is in order. Your doctor should have known:

- a pressure of 10 is not low
- the amount of pressure needed is not an indication of severity
- weight loss does not preclude the need for cpap therapy
- for those who do lose weight, sometimes the pressure requirement goes down, but it does not typically result in curing OSA

I wonder what machine this doctor has in mind for you. Start researching now before she hands you something. At the very least, I would suggest you insist on a machine with monitoring capability (not just compliance reporting).

She said I would only need to use the machine at 6 or 7, to get to an "acceptable/normal" number of events. She didn't seem to think it necessary to run it at 10 so as to get zero. I asked about a machine w/ feedback data and she said she never uses them: either you feel better or you don't. The more I think about it, the less I like this doctor. I do have the reports, so I should be able to show them to someone else, right?

Since she has agreed to give you CPAP (prescription) get it hardcopy from her office as well as a copy of your sleep studies.

That way if you want to break off relations you have what you need.

Don't just go in there and let them give you a machine. Ok if you take a machine you like, but get the script and file it.

How does this work? When I get a script for meds, then go to the pharmacy for the meds, I have to give up the script to get the pills. If she gives me a machine at the office (which she seems inclined to do), are you saying I could also get the script and then get another machine covered my insurance? How?

svh, yep, just about exactly as you said.

Get your Dr. to hand you a prescription for a CPAP, and insist on it having "with heated humidifier" written on it at the very least. There are several other items you could try to get the Dr. to specify on the prescription, such as "with CFlex" and "including software, reader and associated hardware".

There are some of the posters here who are much more savvy than I am about what a prescription should/needs to read, but once you have that AND your complete sleep report in hand (yes, get a complete copy of THAT, too!!), then you are free to go to whoever or wherever you want to get the prescription filled. And this is not something "extra", you are ENTITLED to both! You may have to be a bit firm, but it will pay large dividends in the long run, not to mention saving you quite a few $$ in the short run and making sure you get the XPAP you really want and need.

Best of luck!

Kajun

This therapy WORKS!!!

Two things. First, you need a sleep doc instead of a pseudo sleep doc. Second, insurance does not pay for "software, reader and associated hardware". You are on your own buying this peripheral stuff.

But, do check with your DME for software and reader costs. US Expediters is up to something like $ 184. My DME charged $ 100 for the same stuff.

My only comment is that I actually started losing weight when I went on my machine. Apparently, since I am actually getting sleep now instead of waking up all night long my metabolism is getting better.

Two things. First, you need a sleep doc instead of a pseudo sleep doc. Second, insurance does not pay for "software, reader and associated hardware". You are on your own buying this peripheral stuff.

Actually, at least one insurance company has reimbursed the claimant for the card reader, software, and an additional card. I am the claimant. Insurance is the State of NC Employee's Plan, BC/BS is the claims processor.

WOW, cwsanford. You are literally the first person on this board that I recall EVER saying that. You must have some amazing insurance!

Ok, you have several questions here, all good ones.

First off, your doctor is not at all "uneducated" and in fact sounds like an excellent doctor. The doctor was clearly willing to work with you on whatever you wanted and more importantly - wanted to work with you to get your symptoms under control without the need for machines and medicine. So many people are ready to jump into medicines and machines when in in all honesty it isn't always needed.

You do in fact have fairly mild sleep apnea. The excellent thing for you is that while you do have a moderate AHI your O2 levels are outstanding, so many of the more serious consequences are not much of an issue for you. This absolutely gives you time now to try and do many of the things that we can all do ourselves to alleviate our own issues - primarily of course being weight loss.
Also in your case, your pessure needs are very low. This is all the more reason to try and alleviate the symptoms without using an xpap or surgical methods. While pressure is not a direct indication of severity, a low pressure may indicate that a slight drop in weight will reduce tissue size enough to maintain an open airway without any other means required. A pressure of 10cm did reduce your events to 0, the pressure of 5 dropped you well below the threshold of "normal".
I have often been on the bandwagon of "How we feel is just as important if not more important than our numbers.". The only caveat to that being that the numbers need to be low enough to adopt that stance. If our sats are above ~92% and our AHI is around ~15-20 or lower than at that point I strongly advocate going by how we feel rather than focusing so much on the numbers. Hey if you feel great, your sats are up there and your AHI is fairly low... who really gives a flip if you have an AHI of 6 or an AHI of 10?? Quit worrying and enjoy life!
However if it does make you feel better (and that is an imporant consideration) go for a unit with data capabilities - and it sounds like the doctor is more than happy to work with you to get what you want.
Your insurance will cover the unit for you since your AHI is high enough and you have had a sleep study. Typically, the Sleep Lab has you sign a form when you go in asking if you have a preference for a DME company. You most likely signed the form stating you didn't have a preference. Your Sleep Doc most likely has a company they are familiar with using and that they know will accept your insurance. They will normally fax that prescription and a copy of the sleep study to that company and they will contact you to setup delivery. They will bill your insurance for you and handle all that stuff.
If you wish you can still use any DME company you want. If you want your insurance to cover the unit you will need to go with a company that is able to bill your insurance. Ask your doctor or the office staff about this. They may well know companies in your area as well as which ones can bill your insurance. You could also call your insurance and get this information though it may not be as accurate (Customer Service at insurance companies for these sorts of questions is notoroiously inaccurate judging by many of the posts here).
Your insurance will only cover 1 machine for you (except in rare extreme circumstances).
Most doctors will gladly give you a copy of both the prescription and your sleep study. The norm is just to fax it off to whatever DME company is in your insurance, but if you ask they will give you copies and/or fax them for you.
What many here have done is to have the order sent to a DME company, then they either go to the location for the business and look at different machines and masks or the company will send someone to your home - though often with a much more limited selection of machines and masks - sometimes only 1 type of each - for obvious reasons.

I think you need to recalculate out your AHI.

1. Take the time spend "sleeping" (not the time at the lab) and divide it by the number of events seen during that session (i.e. 14 Obstructive Apnea + 193 Hypopnea =207 events). If your study was a Split-night, you use only the data from the first half of the study.

For example, if you slept for 412 minutes you would first determine the number of hours (412min. /60=6.86 hours). Then take the 207 SDB events seen and divide by # hours, so for the diagnostic portion of the study your AHI was: 207 events divided by 6.86 hours = 30.17.

AHI >30 = SEVERE diagnosis. This will be your BEFORE therapy AHI.

AHI= SUM of both Hypopnea + Apnea events divided by 60.

2. You should find/see on your PSG report (you did get a copy of the report? if not you will need it later on):

Wake
Stage1:
Stage2:
Stage3/4:
REM:

The above should be followed by some percentages (%) which indicates the quality of your sleep architecture. Most patients with untreated OSA don't have much Stage 3/4 (aka Deep Sleep) and may or may not have any REM. No REM means no dreaming. Most restorative effects of sleep are thought to be restored in non-REM Deep Sleep and REM sleep.

SAO2 Desaturations: When you are awake sitting there in the chair they measure your blood oxygen level with a pulse oximeter. Normal is anything over >95% with healthy lung function. If you visited a ER and your level dropped by 3% they may even put you on supplemental oxygen. For OSA, if your level drops below 89%< it becomes medically significant.

If your levels were dropping due to untreated OSA, they should return to normal with CPAP pressure as it forces oxygen into your lungs while performing the stent.

Titration: All the above items would be looked at for improvement over the diagnostic portion of the study. If your AHI drops from the Severe 30 range to below 5, that is considered treated and the AHI a non-OSA patient would have. CPAP should also improve the sleep architecture above by increasing Deep Sleep (Stages 3/4) and REM percentages. Stage2 percentages should drop with better quality sleep.

So CPAP doesn't only stop the OSA SDB events, it improves your blood oxygen levels destined for the brain, heart and other vital organs thereby improving cognitive functions, it also should improve your sleep and get you dreaming again. It will also jump-start your metabolism combined with other factors.

They are probably not in a big hurry for your cpap machine because it doesn't appear that your SA02 levels were all that critical (unless you had a stroke or cardiovascular disorder).

You can compare your numbers from your PSG's to the legend below and get an idea on where you are at:

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%

1. Take the time spend "sleeping" (not the time at the lab) and divide it by the number of events seen during that session (i.e. 14 Obstructive Apnea + 193 Hypopnea =207 events).

Total sleep time was 301.5 minutes= 5.025 hours
207 events (14 apneas, 193 hypopneas)
AHI=41.2, exactly as the report stated.



2. You should find/see on your PSG report (you did get a copy of the report? if not you will need it later on):

Wake:146
Stage1:3.3%
Stage2:73.3%
Stage3/4:1% stage 3, 15.8% stage 4
REM:6.5%
67.4% sleep efficiency


Average oxygen sat: 97%, minimum 92% (she said if I had been a smoker, this would have probably been 80% geiven my AHI)


Titration: All the above items would be looked at for improvement over the diagnostic portion of the study.
During titration:
Wake:162.5
Stage1:2.4%
Stage2:76.4%
Stage3/4:4.6% stage 3, 6.9% stage 4
REM:5.9%
64.1% sleep efficiency


They are probably not in a big hurry for your cpap machine because it doesn't appear that your SA02 levels were all that critical (unless you had a stroke or cardiovascular disorder).

I haven't/don't.

You can compare your numbers from your PSG's to the legend below and get an idea on where you are at:


APNEA = mean duration of mine:11.8 seconds, longest 16 seconds

HYPOPNEA =mean duration 16.6, longest 32 seconds, lowest oxygen sat 92%


EPWORTH SLEEPINESS SCALE mine was 10

RESPIRATORY EFFORT RELATED AROUSALS (RERAs)= I don't see this on my report

Sleep Efficiency = 67.4 pretreatment, 64.1 on titration night