Titration results - Should I be mad?

Hi everyone

It took a couple weeks, but i finally got my titration results. Let me know what you think

Study ran from 10:56 pm to 6:19 am. Total sleep time was 143 Minutes or 38.0% sleep efficiency of 377 minutes. 28 awakenings with total awake time after onset of 187 minutes. Sleep latency was 46 minutes and REM latency was 98 minutes. 64.5% supine.

Stage 1 - 12.5% Stage 2 - 80.1% Stage 3 - 3.8% Stage REM - 3.5%

76 arousals for arousal index of 31.8 and 83 stage shifts.

CPAP was initiated at 8 cmh20 and snoring was eliminated at 8. There were 66 respiratory events of 56 apneas (0 osa, 0 mixed, 56 central) and 10 hypopneas. The mean oxygen during the study was 96% with a min of 81%. There was 3.8 minutes of sleep time below 90% and 3.1 minutes below 88%. No cheyne -stokes.

I was transitioned to bipap due to persistent centrals. A backup rate of 11 breaths/minute was added to bipap of 18/14 cmh20. Leaks were minimal.

Pap. Backup. TST %Sup. SupAHI. REM. RAHI.CAI. HI. AHI. Arldx. Nadr. AvgO2.
08 0 17.5 min 100% 65.1 0 min -- 51.4 13.7 65.1 30.9 81% 94%
10 0 47min 100% 15.3 0 min -- 10.2 5.1 15.3 15.3 88% 94%
12 0 21min 90% 34.7 5 min 12.0 34.3 2.9 37.1 31.4 87% 96%
14/10 0 15min 40% 50.0 0min -- 52.0 4.0 56.0 40.0 85% 96%
16/12 0 31.5min 0% -- 0min -- 1.9 0.0 1.9 19.0 90% 95%
18/14 0 10min 15% 40.0 0min -- 42.0 0.0 42.0 54.0 87% 96%
18/14 11 1.5 min 100% 0.0 0min -- 0.0 0.0 0.0 0.0 95% 98%

5 periodic limb movements, 3 associated with arousals. PLM 1.3

Average heart rate 68. 65 - 80 range. No arrhythmias.

Diagnosis
Obstructive sleep apnea
Treatment emergent sleep apnea

1. At 16/12 bipap the off-supine apnea/hypopneas and arousal indexes normalized. Snoring eliminated. Oxy sat maintained above 89%. (To me,this should be the end of the discussion). At 10 cmh20 less centrals were seen during supine NREM sleep.

2. Abnormal sleep architecture due to respiratory events, PAP, and first night effect.⁣Sent

Recommendations
CPAP of 10 cmh20. Should AHI remain elevated, patient should return for a full night titration starting at 16/12 with backup rate of 11. (You don't say, Sherlock!?)



Okay, I'm a side sleeper. The 16/12 with 0 backup fixed me!! My low sleep/REM times makes it difficult to get my diagnosis right, I'm sure, but am I crazy to say that when you can hit a home run you shouldn't settle for a base hit?

ShallowBreather wrote: ↑

Thu Sep 16, 2021 12:08 am

but am I crazy to say that when you can hit a home run you shouldn't settle for a base hit?

The medical profession got you to first base. Now go for an inside-the-park home run. The medical profession is no longer of much help. It's your job to get around the bases.

Get the right machine. Get OSCAR. Optimize your CPAP therapy.

Awww man, You have every right to be mad. I would be having smoke coming out of my ears.

Essentially they want you to fail cpap for some undetermined time using fixed cpap at 10 and having 15 or more centrals per hour all night long before they will consider ASV (or some model machine with a back up rate) trial.
Is this tactic insurance related???? Dunno but insurance coverage may be a factor.

All the time you are miserable and will continue to be miserable with 15 centrals per hour.

What I don't understand .... were centrals present on the diagnostic sleep study??? Or did they pop up with the beginning of cpap treatment? I couldn't find that bit of information in your past posts but I could have missed it.

Pugsy wrote: ↑

Thu Sep 16, 2021 6:41 am

What I don't understand .... were centrals present on the diagnostic sleep study??? Or did they pop up with the beginning of cpap treatment? I couldn't find that bit of information in your past posts but I could have missed it.

That’s a two-part answer. First, the reason that I initially went to the doctor was not for snoring, although I do on occasion store, but because my wife was saying that I was creating to breathe in the middle of the night. So my initial complaint was central apnea, even though I didn’t know the name of it yet. And secondly, to answer your question, during my initial sleep study when I did not have any treatment or mascon I was showing nine centrals per hour. That number remained about the same under CPAP level six.

What documentation was there for the obstructive sleep apnea diagnosis? Obstructive/hyponea index during diagnostic study?

Pugsy wrote: ↑

Thu Sep 16, 2021 8:02 am

What documentation was there for the obstructive sleep apnea diagnosis? Obstructive/hyponea index during diagnostic study?

Here is what I put on the forum after the first sleep study:

During the no-mask period, I had 42 respiratory events consisting for 15 apneas (3 obstructive, 1 mixed, and 11 central) and 27 hypopneas. I can't figure out the difference between a central apnea and a hypopnea. ??? AHI was 35.5 and CAI (central apnea index) was 9.3. REM AHI was 0.0. non-REM AHI was 35.5 and arousal index was 34.6. Average oxygen 92.0% and minimum oxygen saturation of 80.0% YIKES! I was below 90% about 10 total minutes. Supine the entire time.

Then they put an Eson 2 on me. Only minor leaking. About 5 hours on the mask. Snoring was eliminated at 6 cmH20. 52 respiratory events (more, but it was a much longer time) consisting of 43 apneas (0 obstructive, 0 mixed, 43 central (100%)) and 9 hypopneas. So, there I am with my mask on, and the average oxygen saturation was 95.0% with a low of 84%. I was under 90% oxygen for about 3 minutes. What gives with that??

Thanks for refreshing my memory. Bear with me...I am typing one handed and it was. often hard enough for my fingers to keep up with my brain with 2 hands....impossible now.

It appears that the hyponea numbers on the diagnostic (without mask) sleep study earned you the OSA diagnosis.
Hyponeas are generally considered obstructive in nature and while they can sometimes be central in nature...when the sleep study is done in a lab setting it is usually easy to spot the difference so we assume obstructive.

I am sorry but all your O2 sat number questions I can't explain. Above my pay grade.

ShallowBreather wrote: ↑

Thu Sep 16, 2021 8:28 am

I can't figure out the difference between a central apnea and a hypopnea. ???

Central apneas are generally flagged when there is no air flow for at least 10 seconds but the reason for the no air flow is simply no effort is being made to breathe. Hold your breath for 15 seconds...that's essentially what a central apnea is.
One or two centrals randomly here and there aren't usually any big deal but when we have enough of them back to back it can cause desats and then it becomes a big deal. It can also disturb sleep in general...cause arousals and when arousals are high in number it becomes a big deal

Hyponea....a reduction in air flow of between 30 and 79% that lasts at least 10 seconds. Above 79% reduction and it gets the obstructive apnea label. Hyponeas are usually considered obstructive in nature, like OAs, because the reduction in air flow is because of the airway tissues sagging/collapsing and either fully or partially blocking the airway to cause the air flow reduction. Hyponeas can and will disturb sleep and even cause desats when the reduction in air flow is bad enough and a person has enough of them back to back. They are part of the overall AHI used to diagnose sleep apnea for a reason....they are bad guys and a lot more than just "shallow breathing". I think of them as baby OAs wanting time to grow up to earn the OA label. Hyponeas are so much more than a person taking small breaths as opposed to big deep breaths.

Hope the above helps you understand your results a little better.

Your situation was/is complicated by the 9 central index during the diagnostic portion of your sleep study.
That's enough centrals to at least put up warning flags that a person has not only OSA but central sleep apnea as well..so a potential diagnosis of complex sleep apnea.
Further complicated by the fact that your central index is made worse by adding cpap to fix the OSA side of things.

Have you actually had a chat with your doctor about any of this? Find out why he is choosing this way to go?
Put his feet to the fire and have him explain his rationale????

What is it that you wish from us...here??? Advise on what to do? I don't mean to sound flippant or rude...I truly understand your frustrations here and rightfully so but there may be reasons behind the doctors plan (whatever that plan might be).
His reasons could very well be legitimate or he could be a dufus. Insurance hurdles for the expensive machine is possibly a factor. The fact that there is a remote chance that cpap "might" fix the original central problem is a potential factor.
The fact that sometimes people who find that sometimes people whose central apnea is worsened by sleep apnea "might" go away with the "give it time" approach might be a factor.

All the recommendations talk is from the sleep tech/dr. My primary is out until Monday. I have preemptively emailed him after seeing the sleep study results, and I hope he sees this my way.

Sorry for the confusion.

Ahhh. Need another dose of that patience pill.
See what your doctor wants to do before getting your blood pressure up.

At least now you should have a clearer understanding of what some of the hurdles might be and your options and I hope a clearer understanding of what you are seeing in the reports.

FWIW I do understand totally how difficult the "patience pill" is to swallow. I have a big one sitting in front of me right now and it isn't the bum hand thing. Long story and no need in going in to it right now.

Yes, you have me figured out! Lol

I’ll pray for you and your patience pill. You’ve been a blessing to me!

Update

My primary doctor, not a sleep doctor himself, got my messages and agrees that he can’t see the sense in putting me on CPAP 10 when the tests clearly showed bilevel 16/12 was better for me. He’s going to reach out to the sleep tech doctor who wrote the results and get them to explain the reason for not giving me the one that works best.

He also said he has the option of referring me to a sleep disorder specialist who is more skilled at reading my titration results. I asked for him to hold that as the next option if he can’t get the sleep tech doctor to budge. (Since he’s not a sleep specialist he’s reluctant to make the move on his own, but I’m finding him to be receptive to logic.)

And I’m adding more tired days to my calendar, but excited for his advocacy!

ShallowBreather wrote: ↑

Tue Sep 21, 2021 10:18 am

He’s going to reach out to the sleep tech doctor who wrote the results and get them to explain the reason for not giving me the one that works best.

That's a good doctor who will, in effect, challenge directly what another doctor is doing.

So my primary doctor got together with the sleep Doctor who wrote the titration results, and they decided that it was best to refer me to a sleep disorder specialist because neither one of them wants to take the responsibility for signing off on the bilevel machine.

So I finally get a call from the scheduler at the sleep disorder specialist and I will be squeezed in on November 16. This saga started in July!

I know that I’ve been counseled here to take a chill pill, but this is a little ridiculous, so I have made a decision do you use the bilevel machine that my mom offered me, which I’ve set at 16/12 pressure as per my titration best results. I’ve been sleeping very well.

Ever feel like your health isn’t anybody else’s priority?

Sleep well friends.

ShallowBreather wrote: ↑

Wed Sep 29, 2021 11:56 am

Ever feel like your health isn’t anybody else’s priority?

Every day.
The sad truth....our health really isn't anyone else's priority.
Off I go today for one of the new hoops I have to jump through to eventually maybe get some relief for my problem.
I already took 2 chill pills this morning.
I probably will need more pills after this BS appt today.