New to this- Husband vpap III 5 days but not taking breaths

Casiesea wrote:Echo - Within normal limits - Left atrium contracting more frequently then the other chambers (having trouble keeping up with the rest of heart), however test results still considered normal. Probably related to sleep problems...

What do you all think?

I think that atrial fibrillation (or flutter) in anyone (let alone a 39 year old) should not be considered a "normal" phenomenon.

-SWS wrote:President-elect Doc1...

Just goes to show ya, nothing gets by -SWS!

Banned wrote:My problem is I also don't mind messing with sleep medicine professionals

You give yourself far too much credit.

Banned wrote:Example: The Adapt SV literature clearly states that an EEP of 8cmH2O and MIN PS of 5cmH2O is a good starting point for 90% of Adapt SV patients.

Wrong again. What is very clearly stated is that

Start therapy at default settings.
ASV Mode default settings:
EEP = 5 cm H2O (EEP = EPAP)
Minimum Pressure Support (Min PS) = 3 cm H2O
Maximum Pressure Support (Max PS) = 10 cm H2O

goose wrote:I would also be quite interested in what SAG would opine here!!

SAG wold opine that "Doc #1" has chosen to order "off the menu" a bit. The AdaptSV titration did not show results at EEP 10 cmH2O:



but they are opting to try that setting. However, since the titration showed that there continued to be obstructive events at the pressures trialed, then attempting to address them seems to be an appropriate course of action. The question would be whether you would want to address them by increasing EEP or by increasing PS. Increasing PS could be destabilizing to the CompSAS (let's say that CompSAS is present.) Might 10 cmH2O be a bit aggressive? Got me. They're there looking at the stuff.

Speaking of which, as everyone has noted (with the obvious exception of one poster), trying to understand things with snippets of information is difficult. Making treatment decisions is impossible.

As Lubman noted, they should be doing Adapt SV downloads and reviewing the data. There can be clues to treatment efficacy even if you're using the "unenhanced" AdaptSV.

SAG

StillAnotherGuest wrote: The AdaptSV titration did not show results at EEP 10 cmH2O:

but they are opting to try that setting. However, since the titration showed that there continued to be obstructive events at the pressures trialed, then attempting to address them seems to be an appropriate course of action. The question would be whether you would want to address them by increasing EEP or by increasing PS. Increasing PS could be destabilizing to the CompSAS (let's say that CompSAS is present.) Might 10 cmH2O be a bit aggressive? Got me. They're there looking at the stuff.

With permission from the Board, would it be reasonable to recommend an interim pressure of EEP 8cmH2O + MIN PS 3cmH2O = (IPAP) 11 cmH2O?

Banned

Banned wrote:With permission from the Board, would it be reasonable to recommend an interim pressure of EEP 8cmH2O + MIN PS 3cmH2O = (IPAP) 11 cmH2O?

https://www.youtube.com/watch?v=NzlG28B-R8Y






.

You will have to forgive me...they are not in order.

Initial PSG from 8/26/05 (4 pages)
Cpap titration from 4/27/06 (5 pages)
Bipap titration 1/22/08 (4 pages)
Adapt SV titration 2/25/08 (7 pages)

http://s281.photobucket.com/albums/kk216/casiesea/

Casiesea, what happened between the initial PSG on 8/26/05 and the CPAP titration on 4/27/06?

Also wondering how your husband initially took to CPAP.

Submitted, for your approval (every big thread needs a "theme" acronym. How about "The TZ Thread"?)

1. If each of the studies was performed, scored and interpreted by different equipment, technicians and physicians, then there are very likely differences in the interpretation of the data. The treatment team you end up going with should be looking at the raw data (actual PSG) to base treatment decisions.
2. I could see where someone might say that there is no Complex Sleep-Related Breathing Disorder (CSBD)(not agree with, just perhaps see their point of view). The initial PSG shows REM dependency (AHI 67.0 vs. 5.8) and position dependency (supine AHI 33.7 vs. 4.2). Just about all the centrals are in REM, which is not typically characteristic of CSBD (which is largely a "light NREM", or Stage 1-2 phenomenon).



3. I would go back and review that all the events scored in the original PSG are truly central or mixed. They could very well be purely obstructive. In the subsequent studies, REM events are quite effectively controlled regardless of approach.
4. The basic CPAP titration is not all that bad.
5. The 1/22/08 study, where more aggressive pressures are employed, starts to generate more problems than it corrects. Centrals reappear (or "appear", depending on your school of thought).
6. Starting in 1/2008 there appears to be REM suppression and sleep maintenance issues. R/O drug effect.
7. The AdaptSV titration shows two areas of effective treatment. The first area has mostly SWS, which tends to be quite stable re: respiratory events (there'd be no events regardless of treatment choice). Looking for the selection of effective treatment pressures in the second area of event-free sleep might be a better source.



8. The events in CSBD tend to be periodic in nature. Event begets event. So if you have one event, and the next event doesn't come till 10 minutes later, that's not CSBD.
9. So again, trying to explain the rationale of Doc #2 who said no CSBD, the CPAP looked good enough to stay there. But the aggressive BiPAP titration generated events, so there certainly appears a tendency to CSBD once the attack gets aggressive. Those events do look dense enough to have periodicity.
10. There is likely an additional problem underfoot that leads to quality of sleep issues. The middle of the night in 1/22/08 and 2/22/08 is not where a 39 year old should be.
11. A certain amount of patience and less dial wingin' will be helpful. If the problems include overall sleep quality, then dial wingin' won't help.
12. Unstable sleep (from any cause) may be discernable on the AdaptSV downloads.
13. You may be "SOOOOO close" that you are, in fact, already there. If some of the problem is due to compliance with therapy ("I hate this thing"), which generates sleep maintenance issues, then pressure increases, which may or may not change AHI, may make overall sleep quality worse.
14. Which makes -SWS questions extremely pertinent. Is the problem AHI or compliance?

SAG

StillAnotherGuest wrote: 10. There is likely an additional problem underfoot that leads to quality of sleep issues. The middle of the night in 1/22/08 and 2/22/08 is not where a 39 year old should be.

Other than compliance, could you provide a short list of examples of additional problems that could lead the quality of sleep issues?

Banned

Thank you for your thoughts, SAG! I appreciate you taking the time to look at this.

Can someone explain it to me?

The length of time between psg and cpap titration was r/t pregnancy (mine, not his) and delivery. Mom and baby had a few health issues and he had to postpone his titration and dr appt (they put him to the back of the list after that).

He never did well on CPAP (could it have been mouth leaks?). Jan 22, 2008 they did a cpap titration starting at pressure of 5 and went to 12 before they started the bipap.

8/26/05 + 4/27/06 study - same tech / same center / same doc
1/22/08 diff tech / same center / same doc
2/25/08 diff tech / diff center / diff doc read results (from doc 1's lab)

R/O Drug effect???

He is on provigil 200 mg and generic allegra. He started them both right before the 2/25 study. I think he was taking Zyrtec in Jan. He has never done any kind of illegal drugs (not even pot) at least thats what he tells me - maybe he just didn't inhale.

Where should a 39 yo be in the middle of the night?

There are several different types of Allegra/Zyrtec. Which type did he take, and what time of day did he take it?

The graph of the sleep stages (W, R, 1, 2, 3, 4) is called a hypnogram. The letters and numbers refer to the sleep stages (Wake, REM and the 4 NREM sleep stages). The pattern of sleep in the hypnogram is called the "Sleep Architecture". Normally, sleep progresses from wake, through light sleep (Stage 1 and 2), followed by deep sleep (Stages 3 & 4), and finally a REM period. This is called a Sleep Cycle, and takes about 90 minutes to complete. There are usually 4-6 Sleep Cycles per night. Most deep or delta sleep occurs in the first Sleep Cycle. Stage 1 should appear principally in the first sleep cycle. The duration of REM periods increase as the night goes on. Normal sleep stage percentages are Stage 1 5%, Stage 2 60%, Stage 3 & 4 combined 20%, and REM 20%. Delta sleep generally decreases as a function of age. There should only be about 2 - 5 awakenings per night, none of which should be very prolonged. A normal sleep architecture looks something like this:



While the initial sleep study has the general appearance of normalcy, REM is substantially increased. Increased REM can occur as a result of sleep deprivation.

The ASV sleep architecture has significantly reduced and delayed REM. The first REM period is very poorly formed, if, in fact, exists at all. Medications can suppress REM. All of the sleep quality measures are abnormal. Sleep onset is prolonged at 60.5 minutes, sleep efficiency is poor at 76.2%, awakenings are elevated at 28 as are arousals at 108 and wake after sleep onset elevated at 55.5 minutes. The middle of the night has numerous awakenings.

The Physician Summary notes that "Sleep fragmentation improved with VPAP" and "On the post sleep questionnaire the patient thought he slept better than usual". I don't know what sleep fragmentation was improved. The 1/22/08 study has sleep efficiency at 90.4%, wake after sleep onset at 22.0 minutes, total arousals at 96 and awakenings at 27. Sleep efficiency and WASO are MUCH better on that one, the other parameters essentially the same.

The middle of the night in both of these studies has numerous occurrences of Wake. The ASV titration has periods of sustained Wake.

BTW, AdaptSV can have significant trouble as it tries to adjust to Wake/Stage1 transitions.

While chasing the AHI is one way to try to improve sleep, if the actual quality of sleep is poor and quantity is insufficient, then people will never "feel better".

If that ASV night did, in fact, represent a "better" night than usual, then there are significant other issues underfoot. Looking at all facets of sleep hygiene may provide more beneficial results than dial wingin'.

SAG

Zyrtec D (P-ephed hcl/Cetirizine hcl) 5/120 mg - and he took it once a day in the morning. He actually was taking Zyrtec D for both 1/22/08 and 2/25/08. He did not start Allegra (Fexofenadine HCL 180 mg) until March 13 (prescribed by sleep doc #2). I forgot to mention his nicotine gum addiction and Prozac 40mg(started in dec/jan).

I have recently noticed that the jerking/startling movements tend to stop when he has been asleep for a while. I do not know if they start again as he cycles.

2/25/08 - The sleep tech's were waking him up when they came into the room to change the machine. They were turning the lights on and making noise. He did say it took an unusually long time for him to go back to sleep that night.

Doc # 1 called my husband today. She is concerned about the issues he is still having. She listened to everything that has been going on since his last appt (jerk/startling, other docs opinion, heart issues, etc).

She said:
1. She has very little doubt about her diagnosis of complex sleep apnea
2. She thinks the startling could be "sleep starts" but will have to investigate further
3. Is concerned about the settings on the machine and does not want to guess with such a complex case

So...... they are going to do another sleep study on Wed night (What would doc #2 say?). The Resmed rep is coming, too.

Casiesea, I suspect Doc1 is presently pursuing your husband's case correctly.

So far Doc1's only fault is that she has been a scarce resource at times. Understand this problem sometimes arises from professional excellence. If it were me I would have Doc1 as the only chef in the kitchen right now. However, I also think SAG's professional comments are helping quite a few readers here, yourself included, understand what is going on.

I honestly think hubby is in capable hands right now, and that he has Doc1's undivided attention thanks to you!! Highly methodical trial-and-error seems to be absolutely necessary in so many cases of complex sleep apnea. Unfortunately it can be challenging to find that right solution---but there is always some individualized therapeutic "optimum" to eventually achieve (just nowhere near as quickly or easily as in cases of highly basic OSA).

Good luck!



Other opinions/thoughts for Casiesea, please!

-SWS wrote: Other opinions/thoughts for Casiesea, please!

I like Doc #1, too. But, I also liked SAG's old avatar better than his new one. Anyone else want to weigh-in on Casiesea or SAG's new avatar?

Banned

There are a couple of things my husband wants to make sure I add:

- Doc #2 was a complete a**! Questionable ethical behavior on numerous counts.

- Doc #1 was extremely unhappy with 1/22/08 titration. She had specifically requested a certain sleep tech preform the titration and it didn't happen. (I think I said this before)

- He harbors no ill will against his machine and is extremely compliant providing he falls asleep in our bedroom (he obviously does not use it when he falls asleep in his office during the day). We realize the resentment may be subconsious in nature.

- his leak rate is a bit of a problem. It has been over 20L/M lately, but averages in the teens.