Options after Failed ASV Titration-Current Oscar Reports

Miss Emerita wrote: ↑

Thu Jan 18, 2024 1:53 pm

ozij wrote: ↑

Thu Jan 18, 2024 11:39 am

Miss Emerita wrote: ↑

Tue Jan 16, 2024 12:21 pm

I'm mystified why your doctor isn't paying attention to the PLM, which can mess with sleep quality.

Maybe becaus the PLM arousal index is low? (see sleep study, posted after Miss E's comment)

Ozij, I'm curious about this, and I know very little about PLMS. The overall PLMS index seems high, even though the PLMS arousal index is fairly low. Could PLMs be messing with sleep even if there aren't associated arousals, e.g., by messing with sleep architecture? What do you think?

I doubt I know much more than you, Miss E. I assume that sleep architecture is messed up by apneas and hypopneas
In this case, there are so many breathing obstructions and interruptions that there was simply not enough sleep time for PLM's to cause an arousal from.

That said, according this sleep study, the OP has an AHI of 42.3 but an arousal index of 19.1?
So, there's something I don't know about what they call an arousal, what they call a "respiratory arousal" and what they call a RERA.

I'd love hear Rubicon's analysis of that study.

ozij wrote: ↑

Thu Jan 18, 2024 9:30 pm

I'd love hear Rubicon's analysis of that study.

No prob, I got this!

Here's the issue:

JCFlorida wrote: ↑

Wed Jan 17, 2024 10:11 am

It is a challenge to accept that doctors really don't help you track this. You are taught to follow their advice, but when it comes to sleep apnea they just seem too busy. My doctor said his practice handles 300 new patients a month.

That's an unfounded generalization. There's plenty of guys out there who will spend the time to properly explain everything. If somebody claims/appears to be "too busy" then they:

Have NFI what they're talking about and trying to hide that fact;
Lazy;
Overworked to the point of being unable to complete tasks;
Or a combination of the above.

Doesn't really matter tho. If you are not getting product then you need to find somebody else.

So how much time is your MD actually spending with you? On your paperwork, what are the billing codes for the office visits? If he/she is sending in a code for like 40 minutes of face-to-face time and they're only spending like 2, then Houston, We Have A Problem...

Rubicon wrote: ↑

Fri Jan 19, 2024 7:04 am

So how much time is your MD actually spending with you? On your paperwork, what are the billing codes for the office visits? If he/she is sending in a code for like 40 minutes of face-to-face time and they're only spending like 2, then Houston, We Have A Problem...

Thank you for your feedback. The codes that have been used are 95810, 99214, and 94660. I have had one face to face and one zoom call with him, and one other visit with their APRN. Time with them has not been longer than 20 minutes. He has never mentioned anything concerning about PLM's or heart rate. The doctor himself has been surprised by my level of involvement. When I asked about lowering EPR based on what I read on forums like this, he rolled his eyes. He did agree to do it. But I felt he would have kept it on 3 for a lot longer. He does seem to listen, just doesn't seem to be as accustomed with patients who are as engaged with the minutia of cpap efficacy.

He says it takes time to adjust and points to the overall reduction of AHI. As I said, I am willing to continue to use the apap in hopes that I can maximize what it can do for me. Then, if needed, try the ASV. Then I will at least know the pressure settings that work best under apap for my situation that can hopefully inform the settings for the ASV.

ChicagoGranny wrote: ↑

Tue Jan 16, 2024 5:51 pm

JCFlorida wrote: ↑

Tue Jan 16, 2024 4:08 pm

I can share what that looks like on Oscar once I have a week of data on the new EPR setting. That does sound reasonable?

Don't wait a week if there is any significant change.

Hi, These are changes made in last 2 1/2 weeks to settings:
12/30 settings and prior: Min 5, Max 20, EPR 2 - Original settings (Ramp on Auto)
12/31 settings: Min 5, Max 10, EPR 2 - User changed max to be at 95% (Ramp off), Pressure max to high --waking up.
01/02 settings: Min 5, Max 10, EPR 1 - User changed EPR
01/09 settings: Min 5, Max 8, EPR 3 - MD changed Max and EPR during office visit
01/16 settings: Min 5, Max 8, EPR 1 - MD changed EPR after zoom call

SleepHQ Interactive Chart shows impact: https://sleephq.com/public/b5b75c23-0b1 ... 866570a369

Curious if higher min might be worthwhile at some point. Appreciate your opinion.

Please provide the link to a typical night (one night, not historical data) at the most current settings.

JCFlorida wrote: ↑

Fri Jan 19, 2024 1:47 pm

The codes that have been used are 95810, 99214, and 94660. I have had one face to face and one zoom call with him, and one other visit with their APRN. Time with them has not been longer than 20 minutes.

The CPTs for office visits (E&M) are the 9921x.



99214 is for 30 minutes so they fudged on that one. If they used 99214 for the APRN visit that's a naughty. That should have been 99211.

If you feel like it load up the rest of the sleep study, esp. O2 desaturation detail. O & E are correct they messed up the arousals.

ChicagoGranny wrote: ↑

Fri Jan 19, 2024 2:39 pm

Please provide the link to a typical night (one night, not historical data) at the most current settings.

Of course. Here is a typical night:

SleepHQ: https://sleephq.com/public/d97cf32e-8db ... bdcc86ee8f

Rubicon wrote: ↑

Fri Jan 19, 2024 4:38 pm

JCFlorida wrote: ↑

Fri Jan 19, 2024 1:47 pm

The codes that have been used are 95810, 99214, and 94660. I have had one face to face and one zoom call with him, and one other visit with their APRN. Time with them has not been longer than 20 minutes.

The CPTs for office visits (E&M) are the 9921x.



99214 is for 30 minutes so they fudged on that one. If they used 99214 for the APRN visit that's a naughty. That should have been 99211.

If you feel like it load up the rest of the sleep study, esp. O2 desaturation detail. O & E are correct they messed up the arousals.

Sure. The O2 desaturation details was on previous post. That is all I have from that. Just ordered a Wellue O2 ring to track O2. Here is the first page describing protocol and actual sleep statistics:

JCFlorida wrote: ↑

Sat Jan 20, 2024 12:18 pm

Sure. The O2 desaturation details was on previous post. That is all I have from that.

Needed to know the number of desats.

As the oil driller said....

Rubicon wrote: ↑

Sat Jan 20, 2024 1:02 pm

JCFlorida wrote: ↑

Sat Jan 20, 2024 12:18 pm

Sure. The O2 desaturation details was on previous post. That is all I have from that.

Needed to know the number of desats.

As the oil driller said....

Rubicon,
That report is all I have from the sleep study.

Rubicon wrote: ↑

Sat Jan 20, 2024 1:02 pm

As the oil driller said....

Oh well...

ozij wrote: ↑

Thu Jan 18, 2024 9:30 pm

That said, according this sleep study, the OP has an AHI of 42.3 but an arousal index of 19.1?
So, there's something I don't know about what they call an arousal, what they call a "respiratory arousal" and what they call a RERA.

From a practical perspective, every obstructive event results in an arousal. However, you don't need an arousal to score an obstructive apnea, and since they're using the 4A Hypopnea Rule, arousals cannot be used to score hypopneas. So even though there's something obviously wrong we are unable to summon the NPSG Police. We need to see the Desaturation Index to determine if there's a major SNAFU, and this would be in the Long Report.

Rubicon wrote: ↑

Sun Jan 21, 2024 3:15 am

ozij wrote: ↑

Thu Jan 18, 2024 9:30 pm

That said, according this sleep study, the OP has an AHI of 42.3 but an arousal index of 19.1?
So, there's something I don't know about what they call an arousal, what they call a "respiratory arousal" and what they call a RERA.

From a practical perspective, every obstructive event results in an arousal. However, you don't need an arousal to score an obstructive apnea, and since they're using the 4A Hypopnea Rule, arousals cannot be used to score hypopneas. So even though there's something obviously wrong we are unable to summon the NPSG Police. We need to see the Desaturation Index to determine if there's a major SNAFU, and this would be in the Long Report.

Thank you for the explanation. I ordered the Wellue o2 ring. Should arrive today. I will have to read up on it a bit more to see how to integrate and interpret with Oscar. Hopefully it will provide more info in this area for me. Last night was a better night AHI down to 5.35 (CA 3.65). Thanks again.

JCFlorida wrote: ↑

Sun Jan 21, 2024 8:59 am

Rubicon wrote: ↑

Sun Jan 21, 2024 3:15 am

ozij wrote: ↑

Thu Jan 18, 2024 9:30 pm

That said, according this sleep study, the OP has an AHI of 42.3 but an arousal index of 19.1?
So, there's something I don't know about what they call an arousal, what they call a "respiratory arousal" and what they call a RERA.

From a practical perspective, every obstructive event results in an arousal. However, you don't need an arousal to score an obstructive apnea, and since they're using the 4A Hypopnea Rule, arousals cannot be used to score hypopneas. So even though there's something obviously wrong we are unable to summon the NPSG Police. We need to see the Desaturation Index to determine if there's a major SNAFU, and this would be in the Long Report.

Thank you for the explanation. I ordered the Wellue o2 ring. Should arrive today. I will have to read up on it a bit more to see how to integrate and interpret with Oscar. Hopefully it will provide more info in this area for me. Last night was a better night AHI down to 5.35 (CA 3.65). Thanks again.

Hi, Just FYI, I wore O2 Ring for first time last night. Here are the numbers:

Duration: 9h15m20s
O2 Score: 9.1 <90% time: 12s
Drops over 3%: 24 times ODI 3%: 2.6/h
Drops over 4%: 15 times ODI 4%: 1.6/h
SpO2 Highest Average Lowest
SpO2: 99 - 96 - 88
Pulse Rate: 85 - 56 - 48