CPAPtalk.com

Echo, I agree with your overall views about sleep medicine. What a young, under-explored branch of medicine IMHO.

Here's an interesting article for anyone interested in the behind-the-scenes story of how Cyclic Alternating Pattern (CAP) assumed a role in sleep diagnostics:
http://www.protomag.com/issues/2007_fal ... print.html

Cyclic Alternating Pattern is not yet embraced by most of the sleep community. However, note the seminal references footnoted in that article.

echo wrote:At the university hospital clinic I go to, there are no neurologists in the sleep clinic (only pulmonologists) - yet these people are all interpreting our EEGs. Am I missing something?

I don't think it should be a problem because the extent of the EEG interpretation is limited to about 3 channels and the staging of sleep. Yet, they should all have the knowledge necessary to recognize abnormality that requires a full "real" EEG and/or passing the torch to the neurologists.

-sws wrote:Cyclic Alternating Pattern is not yet embraced by most of the sleep community.

And since that stuff has been out for about 20 years, I doubt that it ever will. Some (all) of the problem is the endless loop where only one software package (that I know of) scores CAP, so most people can't become familiar with it, so there's no demand for it, so the other manufacturers don't put it in their packages, so most people can't become familiar with it....

Interestingly, I see that a lot of the Thomas explanations re: CAP are using the Sandman package.

SAG

IMO CAP data analysis may never gain critical mass unless other correlating physiologic benchmarks are garnered. By itself, ambiguous CAP data doesn't seem to lend much of anything conclusive. Presently CAP vaguely and ambiguously correlates but a few characteristic patterns of bad sleep. However, those same bad sleep conclusions can be efficiently derived via other standard clinical methods. So leaving it at that, I agree that CAP would probably never gain critical mass---nor should it IMO. Perhaps it may never gain critical mass.

However, CAP seems to me as if it might actually be one very promising piece to a greater and more revealing data picture---and yet with too many key puzzle pieces clearly missing in that data puzzle. Sleep medicine really needs more empirical correlates to go with CAP in my opinion as well.

Well, "IMO"....

People don't report out CAP because that would imply that they're using "The CAP Scoring Atlas" by Terzano et al, and there's no way you could do that manually in a timely fashion (even using the software takes too much time). If the rules were made quicker and easier (don't forget you still have to use AASM 2008 or R&K to score the thing once, and there's only so many hours in a day) there'd be a heckuva lot more support for that thing.

There is talk of another method to demonstrate bistability, and you could report out grossly, the same way you report out alpha intrusion (course, we know how standardized that is, too).

Such blaspheme! Somebody deleted Sister Mary Louise's post!! Is nothing sacred?

SAG

StillAnotherGuest wrote:
Such blaspheme! Somebody deleted Sister Mary Louise's post!! Is nothing sacred?

SAG

Mrs. Sag (aka Muffy) cetainly seemed upset too.
O.

ozij wrote:Mrs. Sag (aka Muffy) cetainly seemed upset too.

Boy, I'll say.

Oh well, that's what I get when I marry someone with a Multiple Personality Disorder (for the record, tho, Muffy isn't my wife. She thinks she's married to SAG, who, as we know, is a "virtual" character. She's nuts, I mean like Certified Nuts).

Being married to someone with multiple personalities does have quite a few advantages. Two of them have full-time jobs, one has an internet business and another works for cash "on the side".

Another has no job, but her name is "Candy" and let's just leave it at that.

Hmmm, maybe that's why she (they) have "EDS". Probably more in the neighborhood of "fatigue".

Can get a little dicey around tax time, tho. Working all those "dependents" in is tough.

And performing the ol' "husbandly duties". Back then, it seemed like a great idea. Now, not so much. I mean, SAG needs sleep, too. But then Fred (it's not what you think, "Fred" has another issue) decides she wants to leave. Then all day long, Fred and Jamie are walking up and down the driveway, stay, go, stay, go. Sheesh.

OK, gotta go, need to find somebody to do the laundry. I hope Muffin's around.

Oh. Hi Candy. Fine, whatever.

SAG

SAG wrote: People don't report out CAP because that would imply that they're using "The CAP Scoring Atlas" by Terzano et al, and there's no way you could do that manually in a timely fashion (even using the software takes too much time). If the rules were made quicker and easier (don't forget you still have to use AASM 2008 or R&K to score the thing once, and there's only so many hours in a day) there'd be a heckuva lot more support for that thing.

There is talk of another method to demonstrate bistability, and you could report out grossly, the same way you report out alpha intrusion (course, we know how standardized that is, too).

At this early stage CAP sure seems to me as if it offers more promise for sleep researchers and far fewer dividends in standard clinical practice. I'm somewhat familiar with frequency-domain/spectral-analysis type techniques in non-medical applications. I personally don't see where CAP, as a standalone sleep marker, lends significantly more specificity or sensitivity to disordered sleep than a physiologic marker such as snore. Snore as a physiologic marker of obstructive apnea is both vague and ambiguous. And yet it is a highly useful marker in both screening and pressure treatment. If CAP can presently offer standard clinical practice any advantages as a sleep marker, perhaps it might be as a highly basic correlate similar to snore itself.

If there are yet other physiologic correlates that can be employed with CAP, then perhaps CAP along with those complementary benchmarks may one day enjoy routine application in standard clinical application. In the meantime, some research oriented clinics seem interested in finding out whether treating CAP symptoms alone may yield sleep or other biologic benefits. Other researchers seem interested in further exploring CAP related patterns in epidemiology. So I tend to think CAP is really employed primarily on an exploratory/research basis right now.

The fact that CAP has been around for twenty years or so doesn't detract from CAP's potential IMO. I don't see CAP falling out of favor just yet in the research sector based on current white paper prevalence. Biologically there are some very specific things occurring in that CAP domain relative to disordered physiology. I can't picture CAP researchers walking away from those promising data patterns anytime soon when they probably suspect that there are plenty more undiscovered/unexplored physiologic correlates just waiting to be mined. Look at how long it took PAV to go from research to manufacture---and that challenge is not quite as elusive as decoding CAP with adequate specificity/sensitivity toward useful routine sleep-disorder related benchmarking.

So I guess my summarized take goes like this: Presently CAP is entirely promising to researchers, yet highly impractical and marginally useful at best in standard clinical practice.

Ms. Muffy, played by Glenn Close on the big screen, whispered the other day that the apple of her eye even keeps a watchful eye on the various CAP related research that doesn't seem to be slowing down.

-SWS wrote:So I guess my summarized take goes like this: Presently CAP is entirely promising to researchers, yet highly impractical and marginally useful at best in standard clinical practice.

I'm gonna sorta disagree with that, -sws. Adoption of the CAP Scoring Rules will probably not occur, at least in its present form, to any great extent, but I believe the principle will, that is, the concept of bistable sleep states. And anybody with a PSG machine can look at that (OK, that kinda limits the crowd here).

Too bad we don't have a sleep study lying around here someplace that used Sandman acquisition software.

Now where are we gonna find one of those...

SAG

I sure don't mind disagreement.

I presently have CAP down as promising to researchers but marginally useful at best in contemporary standard clinical practice. So I think your view is that CAP is neither promising to researchers nor useful in clinical practice---meaning CAP will likely go away? Or rather do you think that CAP already has some genuinely useful applications in standard clinical practice? If so, do you view it as just a rough correlate of bistable sleep---or is there something more useful or less useful going on with CAP in standard clinical practice today?

Haven't really followed what Sandman is up to. Does Sandman score bistable sleep using neurodiagnostics? If so, what's your personal take on that one? Thanks.

-SWS wrote:Echo, I agree with your overall views about sleep medicine. What a young, under-explored branch of medicine IMHO.

Here's an interesting article for anyone interested in the behind-the-scenes story of how Cyclic Alternating Pattern (CAP) assumed a role in sleep diagnostics:
http://www.protomag.com/issues/2007_fal ... print.html

Cyclic Alternating Pattern is not yet embraced by most of the sleep community. However, note the seminal references footnoted in that article.

Good article, offers a sliver of hope to those seeking answers to this residual daytime fatigue, yours truly included. I noticed it also mentioned UARS also thought to contribute to that residual fatigue. THIS is what this whole thread is about.

The next question is:
How can today's so called Sleep Specialists call themselves that if they don't know a damn thing about the effects of CAP, UARS?

Seems all they can do is get the patient AHI down close to 5 and call it treated, many cannot even do that it seems without their patients coming here. Obviously this obstructive apnea aspect of it causing the daytime fatigue is a total lie put on by the AASM and the sleep industry.

Why is it a so called Acredited Sleep Lab cannot see these microarousals that some like by Christian Guilleminault suggest?

“The Cyclic Alternating Pattern Demonstrates Increased Sleep Instability and Correlates With Fatigue and Sleepiness in Adults With Upper Airway Resistance Syndrome,” by Christian Guilleminault, Cecilia Lopes, Chad Hagen and Agostinho da Rosa, Sleep, May 1, 2007. This small but intriguing study found that patients complaining of excessive daytime sleepiness have a mild breathing disorder that conventional sleep studies do not detect, but that CAP analysis can.

There were several people here that purchased Dr. K's book on UARS, were they helped by that or was that book just another one with worthless information like Kevin Trudeau puts out. We certainly didn't hear anything from those that did.

That article indicates the ECG has been around since modern sleep medicine since the 1930's, you mean to tell me after 78 years they still haven't figured out a way to score it?

I think if you ask Bev, this thread wasn't about getting a lower AHI, it was finding an answer to residual daytime fatigue. When you do become compliant, when you do get your AHI down, when you rule everything out with blood tests, pain management who else can you turn to? You can't turn to your Sleep Specialist, they think you are doing good, you can't go to your sleep lab if your AHI is below 5 you are fixed.

Maybe they need to start a whole new area in Sleep medicine take it all and classify it as Obstructive Sleep Medicine and stop giving people false hope that it will resolve your daytime fatigue because it doesn't. That is why most people go for treatment and rarely does it resolve it. Yeah it may prolong your life but if you are left so damn tired during the day that you cannot function what good is it doing that.

This is not just a hand full of people with residual daytime fatigue, from what I can tell there are millions out there with the same problem. What I don't understand is if Dr. K, Guilleminault and others know about and know how to resolve it, what is the big secret? What did they find and how was it fixed? Don't tell us we need another PSG because that is BS, I've had 4 and nothing, Bev's had several and still seeking answers. Going back for another "titration study" is a waste of our money and time so we wing dials, maybe we get lucky and stumble across the findings of the secrets.

I suspect they are using very high Pressure Support if they can fix it with a PB425. We know it is not CPAP, we know it is not bilevel with 4 cm pressure support, even the SV don't seem to find it.

Here is another paper on CAP, seems to explain it pretty good:
http://www.measurement.sk/2004/S2/susmakova.pdf

So if I understand it SWS, I guess what you were saying was those cluster/patterns seen on Bev's initial Encore report seem to resemble the CAP shown on page 63 of the susmakova document and of which we have seen here many times. I also look for those patterns because nearly always they include centrals that the person never knew they had.

Omigod! Texas just lost! That means we are BACK IN BUSINESS!!

-SWS wrote:Haven't really followed what Sandman is up to.

LOL! Well, there's a Sandman sitting right here in this thread! Mayhaps we can take a look-see!

SAG

Snoredog wrote:How can today's so called Sleep Specialists call themselves that if they don't know a damn thing about the effects of CAP, UARS?

I've been saying this for years! The imposters indeed!

Snoredog wrote:Obviously this obstructive apnea aspect of it causing the daytime fatigue is a total lie put on by the AASM and the sleep industry.

Well, what do you expect from the same people who killed Kennedy and staged the whole "Moon Landing" scam?

Snoredog wrote:Why is it a so called Acredited Sleep Lab cannot see these microarousals that some like by Christian Guilleminault suggest?

They can't see the NPSG monitor. It's hidden by the piles of money.

Snoredog wrote:That article indicates the ECG has been around since modern sleep medicine since the 1930's, you mean to tell me after 78 years they still haven't figured out a way to score it?

There's at least 5 different ways. Maybe they get confused by all the choices,then get paralyzed and can't make a decision.

Snoredog wrote:You can't turn to your Sleep Specialist, they think you are doing good, you can't go to your sleep lab if your AHI is below 5 you are fixed.

3 channel portable testing will solve all that.

Snoredog wrote:Maybe they need to start a whole new area in Sleep medicine take it all and classify it as Obstructive Sleep Medicine and stop giving people false hope that it will resolve your daytime fatigue because it doesn't.

Then I guess we only need one channel. Whoops! That would be the Encore report!

Snoredog wrote:What I don't understand is if Dr. K, Guilleminault and others know about and know how to resolve it, what is the big secret?

I could tell ya but then I'd have to kill ya.

Snoredog wrote:What did they find and how was it fixed?

Sorry, that's the aforementioned "Big Secret".

Snoredog wrote:Don't tell us we need another PSG because that is BS

Sorry, my bad. Hey Bev, forget everything I said.

Snoredog wrote:Bev's had several and still seeking answers.

Bev's had two.

Snoredog wrote:Going back for another "titration study" is a waste of our money and time

Sorry, I won't do that any more.

Snoredog wrote:so we wing dials, maybe we get lucky and stumble across the findings of the secrets.

GFL.

SAG

Not living in the lingo, I had to search for what GFL mean.

I had a laugh when I found this "Gesellschaft für Labortechnik" as one of the possibilities. ("Gesellschaft" means "company" in German, but it also means "Society").

Which made me wonder, SAG if you were using the salute of the Society that keeps all those secrets...
O.

ozij wrote:Which made me wonder, SAG if you were using the salute of the Society that keeps all those secrets...

LOL! Yeah, there was a salute all right!!

Bev - PM sent.

SAG

Snoredog, I don't think it's possible to deduce CAP activity from patient flow. So most of my CAP thoughts can be vaguely summarized along these lines: "Gee, I bet anxious, interrupted, or even defensive sleepers probably display some interesting CAP patterns. Sure wish we could see that side of the data picture. I think certain types of characteristic CAP activity may reflect something very important in disordered physiology that science is only starting to understand...."

Regarding poor daytime energy, cognitive problems, and even daytime somnolence among CPAP users. I view that as yet another overly complex and extremely difficult constellation of etiologic/symptomatic factors for sleep science to adequately differentiate with today's technology. Case in point: daytime EDS seems to be very common in my extended family---much more so than SDB. So let's extend our scope of analysis beyond my family. Let's run a hypothetical experiment in epidemiology. Let's hypothetically take all sleep disordered breathing patients and send them on a vacation to another planet. Unfortunately a very significant percentage of the remaining population still suffers poor daytime energy, cognitive problems, and in some cases excessive daytime somnolence---and these are all unrelated to both SDB and CPAP use. Unmitigated pain is certainly the central outstanding issue in my case.

Logically we don't expect CPAP to fix all of the health and life-style problems above that can contribute to those daytime symptoms. Nor should we expect that everyone in the real world who makes their way to CPAP will be exempt from the myriad of health and even living-style reasons above, that also cause those same symptoms in the general population. Theoretically we should expect that many people on CPAP still complaining of EDS and daytime energy issues should, in all probability, have some of those same unresolved health and life-style issues accounting for the same symptoms in the general population. But we also know that suboptimal and perhaps even sensory-disruption oriented CPAP therapy will collectively account for some residual symptoms among SDB patients. So we collectively try our best to ensure that our CPAP therapy is not suboptimal. That's a very important function of this message board IMHO.

Given today's technology, it is virtually impossible for clinicians to routinely come even close to being able to differentiate all the interrelated factors of typically "energy-complex" and highly diverse etiologic and symptomatic presentations. That's just my highly unqualified take as a patient.

SAG wrote:LOL! Well, there's a Sandman sitting right here in this thread! Mayhaps we can take a look-see!

Thanks! And hooray!

ozij wrote:Not living in the lingo, I had to search for what GFL mean.

I had a laugh when I found this "Gesellschaft für Labortechnik" as one of the possibilities. ("Gesellschaft" means "company" in German, but it also means "Society").

Which made me wonder, SAG if you were using the salute of the Society that keeps all those secrets...

I had it down to either: 1) Grotesque Flow Limitations, or 2) Girl Friend's Lithuanian.

I was just getting ready to head back to that other thread to see if I could detect any Lithuanian linguistic clues, literally listing or lingering, in Ms. Muffy's lavishly livid literary style... Later, ladies and lads!